LIBRARY OF CONGRESS. 



^v 



©gap. Sopijrigtjt jf a.. 

UNITED STATES OF AMERICA. 




Case of Xanthelasma. 



THE 



READY-REFERENCE HANDBOOK 



OF 



DISEASES OF THE SKIN. 




BY 



GEORGE THOMAS JACKSON, M.D. (Col.) , 



CHIEF OF CL1NJC AND INSTRUCTOR IN DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, 
NEW YORK J PROFESSOR OF DERMATOLOGY IN THE WOMAN'S MEDICAL COLLEGE OF THE 
NEW YORK INFIRMARY; CONSULTING DERMATOLOGIST TO THE PRESBYTERIAN 
HOSPITAL; VISITING DFRMATOLOGIST TO THE RANDALl.'s ISLAND HOS- 
PITALS ; MEMBER OF THE AMERICAN DERMATOLOGICA L ASSO- 
CIATION AND OF THE NEW YORK DERMATOLOGICAL 
SOCIETY; FELLOW OF THE NEW YORK 
ACADEMY OF MEDICINE, ETC. 



WITH FIFTY ILLUSTRATIONS 




frTOF cofj, 



SEP 24 1892 j 



PHILADELPHIA: 
LEA BROTHERS & CO. 

1892, 






^^ 



Entered according to Act of Congress in the year 1892, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress, at Washington, D. C. 



I) U K IS A N ■ , I'EINl'ER 



PREFACE. 



The following pages are intended to present the art of 
dermatology as it now exists. No attempt has been made to 
discuss debatable questions. Hence pathology and etiology 
do not receive as full consideration as symptomatology, diag- 
nosis, and treatment. 

The alphabetical arrangement of the different diseases has 
been adopted for convenience of ready reference. It is hoped 
that the large number of titles from foreign languages will 
prove as acceptable as it is novel, and that the pronunciations 
of the various names will be helpful. I would impress upon 
the reader the fact that in the prescriptions given no attempt 
has been made to translate grains, drachms, and ounces into 
their precise equivalents in grammes, but simply to preserve 
the relative percentages of the ingredients in the old formula? 
and express them in decimals. The decimals may be regarded 
as either grammes or parts. 

It gives me the greatest pleasure to acknowledge in this 
place and always my great obligations to my friends, Drs. 
George Henry Fox, Edward Bennett Bronson, and Robert 
William Taylor. To the first two I owe a great deal of what- 
ever knowledge of dermatology I may possess, and from all of 
them I have received many of those kindly courtesies that 
make a professional life worth living. 

To Dr. F. P. Foster I would return most grateful thanks 
for his kind permission to use the system of pronunciation 
from his admirable Illustrated Encyclopaedic Medical Dic- 
tionary, and for his courtesy in providing me with the pro- 
nunciation of many names in advance of their appearance in 
the same. 



IV PREFACE. 

I would also acknowledge my indebtedness to Dr. A. Rupp 
for special contributions upon eczema and furuncle of the 
ear, and to all those workers in dermatology from whose 
writings I have drawn freely so as to make this little book 
a presentation of modern dermatology. The admirable text- 
book of Dr. H. R. Crocker, of London, has been specially 
consulted by me, and has guided me through many a dif- 
ficulty. 

Messrs. William Wood & Co. and D. Appleton & Co. have 
most courteously permitted me to make use of some papers 
of mine published in The Medical Record, The New York 
Medical Journal, and The Journal of Cutaneous and Genito- 
urinary Diseases during the past years. 

14 East Thirty-First Street, 

New York, August, 1892. 



DISEASES OF THE SKIN. 



PAET I. 

GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

Before we enter upon the consideration of the separate 
diseases of the skin, it will be well for us to refresh our 
memory as to its anatomy. It is not my desire to give a 
complete and exhaustive chapter on this subject, but to 
draw attention to those properties of the cutaneous envelope 
that are of practical importance to us. For a more extended 
consideration of the subject, the student is referred to the 
" Handbook of Skin Diseases" of Ziemssen's Encyclopedia, 1 
where he will find Unna's masterly article. 

The skin is made up of three distinct layers, namely : 1 , 
the epidermis ; 2, the derma, also named the cutis vera or 
corium ; and, 3, the subcutaneous connective tissue. The 
appendages of the skin are the hair and the nails, the seba- 
ceous and the sweat glands. This complicated structure is 
supplied with bloodvessels, lymphatics, and nerves. 

Epidermis. The epidermis is composed of four layers, 
called strata, namely : 1, the stratum corneum ; 2, the stratum 
lucidum ; 3, the stratum granulosum ; and, 4, the stratum 
mucosum. Of these strata, the two that most concern us 
are the first and the last — that is, the stratum corneum and 
the stratum mucosum. The other layers of the skin may, 
for our present purpose, be regarded as simply transition 

1 "Handbuch der Hautkrankheiten," Bd. xiv. Ziemssen's Encyclo- 
paedia. 



26 



GENERAL CONSIDERATIONS. 



layers through which an epithelial cell passes on its develop- 
mental way to become a fully formed and rightly compacted 



Fig. 1. 




Vertical section through the skin. (After Heitzmann.) Diagrammatic. 



ANATOMY OF THE SKIN. 27 

corneous cell. Each of the four strata of the epidermis is 
divided again into layers, but these are of no practical im- 
portance. 

The stratum corneum consists of a series of superimposed 
layers of flattened, elongated cells, that increase in flatness 
from below upward. The upper layers are called scales. 
The cells of each layer are united to each other so much 
closer than the layer itself is united to those above and 
below it, that when an effusion takes place into the stratum 
corneum a layer of cells is raised in the affected area, and 
the fluid is found between two layers. The lamellated 
scaling met with in certain scaly diseases, such as dermatitis 
exfoliativa, in which great plates of scales are readily remov- 
able, is likewise due to this close relation between the cells 
of each layer. This stratum is largely a protective one, its 
compactness affording a fair degree of resistance to injury 
of the underlying, more succulent layers of the epidermis. 

The stratum mucosum is the deepest layer of the epi- 
dermis, and is seated upon the papillary layer of the corium. 
It is composed of several layers of cells, but may be con- 
sidered to consist of two chief layers, namely, the columnar 
epithelium and the prickle cells. The columnar epithelium 
are arranged perpendicularly to the papillae of the corium, 
while the prickle cells, which are polygonal in shape with 
spherical nuclei and with little filaments running out from 
their sides toward the neighboring cells, are arranged in 
strata over them. As the stratum granulosum is approached, 
the prickle cells become flatter, and finally lie with their 
long axis parallel to the general surface. The stratum 
mucosum, also called the rete Malpighii, is the most important 
stratum of the epidermis, and the seat of that most common 
of all skin diseases, eczema. From its lower part it sends 
down projections between the papillae of the corium, which 
are called inter-papillary projections. Most of the pigment 
of the skin is situated in the lower part of the stratum mu- 
cosum. As the upper part is approached, less and less 
pigment is found. The pigment itself is in the form of 
granules and of diffused coloring matter. According to 
Unna the pigment is found even in the upper part of this 



28 GENERAL CONSIDERATIONS. 

layer, while in pathological conditions it may be located in 
the corium. 

From this arrangement of the cells of the epidermis it 
will be seen that nutrient fluids can readily work upward 
from below by means of the little channels formed by the 
interlacing of the filaments running between the cells. 

The epidermis has no bloodvessels. It receives its nutri- 
tion entirely from the corium. Though there are no true 
lymphatics in the epidermis, there are abundant lymph 
spaces between the cells that take their place. Nerves of 
the non-medullated variety have been traced between the 
cells of the epidermis, and have been described by some 
histologists as entering into the cells to end at the nucleus, 
though not to enter it. The final distribution of the nerves 
in the epidermis is not yet fully determined. 

Corium. The corium is composed of white fibrous and 
yellow connective tissue, disposed in horizontal bundles 
above and in oblique bundles below. It is a very dense and 
tough tissue, and is pierced in all directions to allow T of the 
passage of bloodvessels, lymphatics, sweat ducts, and nerves, 
and aifords lodgment for the hair follicles and sebaceous 
glands. It contains a considerable amount of elastic fibres. 
The upper part has been named the 'pars papillaris and the 
lower part, the pars reticularis corii. From its upper part 
it sends off a vast number of projections called papilloz. 
These vary in length, being longest and most marked on the 
ends of the fingers and toes. The epidermis follows these pro- 
jections, and dips down between them. They are readily 
seen as parallel markings on the ends of the fingers. Over 
most of the body surface, the papillae are but slightly 
raised, and merely give a wavy appearance to the upper edge 
of the corium when viewed under the microscope. A fine 
basement membrane separates the corium from the epi- 
dermis. As we reach the lower part of the corium the 
bundles of fibres are less closely crowded together, and be- 
coming successively looser gradually pass over into the 

Subcutaneous connective tissue. This is a loose connec- 
tive tissue with larger or smaller spaces in it, which are filled 
with the adipose tissue. This consists of fat-cells collected 



ANATOMY OF THE SKIN. 29 

into lobulated masses, that in some cases have about them 
a connective-tissue sheath. Each lobule is supplied with an 
afferent artery, a capillary plexus about it, and efferent 
veins. This part of the skin is called the panniculus adi- 
posus, and is found everywhere except in the skin of the 
penis, scrotum, labia minora, eyelids, pinna, and beneath 
the nails. It contributes to the roundness and beauty of 
the body, besides acting as a storehouse for fuel against 
such times as the body cannot gain its proper nutriment 
from food, as in fevers. It also gives lodgment to the coil 
or sweat glands. The lower end of the deep hair follicles 
are also in this part of the skin. The subcutaneous tissue 
merges into the underlying fasciae of the muscles, and the 
periosteum of the bones. 

Bloodvessels. The arteries which supply the skin 
come up from below to form a horizontal plexus in the sub- 
cutaneous tissue from which the vessels proceed perpen- 
dicularly through the corium to form a second horizontal 
plexus just below the papilla?. From the lower plexus 
small branches pass to the fat-cells, sweat glands, and, ac- 
cording to Unna, to the papillae of the hair. From the 
upper plexus branches are given off which enter the papillae. 
There are also branches to the hair follicles, sebaceous 
glands, and the tissue of the corium itself. Papillae that 
give lodgment to a tactile corpuscle have no arterial twig. 
The veins follow the same course as the arteries, but, of 
course, in the opposite direction. 

Nerves. The skin is provided with both medullated 
and non-medullated nerve fibres. We have already learned 
that non-medullated nerve fibres have been traced between 
the cells of the epidermis, some terminating at, if not in, 
the nuclei of the cells. It may be roughly stated that the 
nerves follow pretty much the same arrangement as the 
bloodvessels, forming a sort of plexus beneath the papillae 
and then giving off branches to the vessels, to the tactile 
corpuscles, to the papillae, the hair follicles, the sebaceous 
and sweat glands, and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are located 
in the papillae. They are oval or round bodies, and their 



30 GENERAL CONSIDERATIONS. 

long axis runs longitudinally. Not more than one papilla 
in four is supplied with one of these corpuscles, even where 
they are most abundant — at the end of the index finger. 
They are composed, according to Unna, of large, flat, con- 
nective-tissue cells which are placed one above the other 
like money-rolls, and take up between them the terminal 
branches of the medullated nerves, which on entering the 
bodies lose their medulla and finally end between the cells. 
The transversely striped appearance presented by the 
corpuscles is due to the swollen lateral edges of the cells, 
and the band-like nerve fibres that here and there appear 
upon the surface. 

The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and con- 
sist in a colossal swelling out of the sheath of Schwann, 
forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, faintly 
filamentous cellular substance through the axis of which 
passes a sensitive nerve. As the latter enters the body it 
loses its medulla, and either terminates in the corpuscle, or 
passes through it to enter one or more corpuscles. These 
corpuscles are most abundant in the fingers and toes, and 
the palms and soles. 

Hair. The hair is an epidermic structure which grows 
from a nipple-shaped projection, the hair papilla, situated 
at the bottom of a deep slender pocket or sac-like depres- 
sion in the skin which is called the hair follicle. Com- 
mencing at the papilla it is bulb-shaped. This part is 
called the bulb and fits over the papilla like a cap. On 
leaving the papilla the body of the hair is first called the 
root, and then as it becomes narrower the shaft. The 
diameter of the shaft rapidly decreases until, leaving the skin, 
it terminates in the point. A fully formed hair is hollow, 
its central cavity being called the medullary canal and 
filled with the medulla. This is composed of a column of 
cells arranged in layers, one layer being superimposed on 
another. The main substance of the hair is called the 
cortex, and consists of long spindle-shaped epithelial cells 



ANATOMY OF THE SKIN. 



31 



flattened out into fine bands and running in the long axis of 
the hair. This part of the hair gives its substance and strength, 



Fig. 2. 




— v ar; 



* 







Hair in follicle. (After Kaposi.) 

a. Follicle mouth, b. Neck. c. Arch of follicle, d. Outer, e. inner 
sheath of follicle. f. Hair papilla, m. Fat cells, n. Erector pill muscle. 
ep. Epidermis, s. Mucous layer of epidermis, o. Skin papillae, t. Seba- 
cous glands. /. External, g. internal root sheath, h. Cortex of hair. k. 
Medullary canal. I. Hair root. 

and in it is placed the pigment that determines the color of 
the hair. The outer layer of the hair is called the cuticle. 
It corresponds to the epidermis, and consists of flattened, 



32 GENERAL CONSIDERATIONS. 

non-nucleated, fully cornified cells which cover the hair like 
scales, and overlap each other like shingles. 

The hair follicle is located for the most part in the 
corium, but in some very strong hairs it reaches down into 
the subcutaneous tissue. It is always, excepting at the 
dorsal edge of the eyelids, placed at an angle to the skin, 
and is a permanent structure that is not removed when the 
hair is plucked. It is composed of three layers, which are 
derived from the corium as it dips down to form the follicle. 
Between the follicle and the hair we have the root sheath, 
which is derived from the epidermis. It is composed of two 
layers, which are called the external and internal root sheaths. 
The whole arrangement of the hair and its sheath may be 
graphically conceived by regarding the hair as a blunt needle 
pressed against the skin. The needle would form the hair, 
the epidermis would form the root sheath, and the corium 
would be to the outside of all and form the hair follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers 
and toes, the glans penis, prepuce, labia minora, and the 
vermilion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main varieties 
of hair: 1. Long, soft hair, as of the head and beard. 
2. Short, stiff hair, as of the eyebrows and lashes ; and 3, 
Lanugo, or soft, downy, colorless hair that is scattered all over 
the surface of the body where the other varieties are not. 

Nails. The nails, like the hair, are epidermic structures. 
They are placed on the extensor surfaces of the terminal 
phalanges of the fingers and toes. Their proximal end is 
called the root, under which is the matrix from which they 
grow. On the way to their distal end they pass over the 
nail bed. This is separated from the matrix by a more or 
less convex and apparent line called the lunula. At their 
posterior and lateral margins they are imbedded in a fold of 
skin that is called the nail fold. At their distal extremity 
they are separated from the end of the finger or toe. They 
are formed by the matrix, but in passing over the bed they 
receive a certain amount of nourishment from it, and their 
cells become rapidly cornified. They are slightly curved from 



ANATOMY OF THE SKIN. 33 

side to side, being convex above and concave below, and are 
marked with fine lines. The flesh beneath the nail is the 
same as the skin in general, though without subcutaneous 
tissue. The nail takes the place of the corneous and granular 
layers of the skin. 

Sebaceous Glands. (Fig. 1.) These glands are of the 
racemose variety, and are closely related to the hairs, from two 
to six being attached to each hair, emptying by their ducts 
into the upper third of the follicle. Each gland is composed 
of a number of acini that empty by a common duct. They 
are composed of a delicate structureless capsule, the mem- 
brana propria, which continues along the duct to merge into 
the hair follicles. This is lined with large, though short, 
cubical or cylindrical epithelial cells arranged in one or two 
rows. These are continuous through the duct with cylindri- 
cal cells of the outer root sheath of the hair, and of the skin. 
The interior of the glands is filled with fatty secretion. 
Around the gland passes the external layer of the hair follicle. 

The function of the sebaceous glands is to oil the hair 
and skin, thus rendering them soft and supple, and giving 
lustre to the hair. This oily secretion is produced by the 
cells, which, as they reach the central part of the acini, 
undergo fatty degeneration. The glands are largest in the 
nose, cheeks, scrotum, labia, and about the anus. 

Sweat Glands. (Fig. 1.) The sweat glands are simple 
coil glands that are located in the subcutaneous tissue. From 
here their ducts ascend through the corium in a straight or 
wavy line to the interpapillary spaces, where they enter the 
epidermis, and then the sweat makes its way to the surface 
of the skin between the epithelial cells. The cells lining 
the coil are simple cubical epithelial cells. These are 
seated upon muscular fibres ; and a connective tissue, the 
membrana propria, comes outside of all. The duct is made 
up of pavement epithelium upon a membrana propria. 
When the epidermis is reached the membrana propria is 
lost, and the further track of the duct seems to be made by 
the sweat working its own channel up between the epider- 
mic cells. Unna teaches that the sweat produced by the 
coil glands is mixed with other elements while passing 

2* 



34 GENERAL CONSIDERATIONS. 

through the epidermis, so that the secretion that appears at 
the sweat pores is not the same as that which leaves the coils. 
He further teaches that the office of the coil glands is not 
to produce sweat, but to oil the skin. This theory still 
needs confirmation before it can be accepted as absolutely 
true. His arguments have considerable weight, but space 
will not allow of their statement here. It has long been 
known that there was a certain amount of oil in the sweat. 
Sweat glands are most numerous in the palms and soles. 

Muscles. The skin is provided with muscles, both of 
the striated and unstriated variety. The striated muscles 
are found in the face and nose. The majority of the muscles 
of the skin are involuntary muscles. In the scrotum they 
run parallel with the raphe. On the penis and about the 
nipple their direction is circular. The arrectores pilorum 
muscles are found all over the body, running in a more or 
less oblique direction from the bottom of several papillae 
down and around a sebaceous gland to be attached to the 
bottom of a hair follicle. By contracting they raise the 
hairs to a perpendicular position, and aid in pressing out the 
contents of the sebaceous glands. 



Diagnosis. 

The Lesions of the Skin. There once was a time 
when skin diseases were classified by their lesions. A 
knowledge of the lesions of the skin is no longerlnecessary 
for purposes of classification, but it is essential to the under- 
standing of dermatological literature. It is well to become 
familiar with these as soon as possible, for, though after you 
have once become versed in dermatology, you probably will 
not stop to think whether a given disease is papular, vesic- 
ular, pustular, or not, but will name it from its physiog- 
nomy ; nevertheless, in doubtful cases the recognition of the 
most prominent lesion will sometimes aid in diagnosis. Fur- 
thermore, time will be saved and clearness gained by using 
the proper phraseology in describing a case. 

We speak of primary and secondary lesions of the skin. 



DIAGNOSIS. 



35 



By the first of these terms we mean the form assumed by 
the efflorescence at its first appearance. By the second of 
these terms we mean the subsequent changes the primary 
lesion undergoes of itself, or as the result of extraneous 
causes acting upon it. In running its course, whether in- 
fluenced by treatment or not, almost every disease of the 
skin exhibits more than one lesion, and we can only speak 
of it as a macular, papular, or other disease from its most 
prominent and characteristic lesion. 

The primary lesions of the skin are the macule, the 
papule, the tubercle, the vesicle, the pustule, the bulla, the 
wheal, and the tumor. The secondary lesions of the skin 
are the crust, the scale, the excoriation, the fissure, the 
ulcer, and the cicatrix. These may be graphically repre- 
sented, following Piftard. 1 



Macule 



Papule 



Tubercle 



Vesicle 



Pustule 



Bulla 



Fig. 3. 



Primary. 



LESIONS OF THE SKIN. 



FiCx. 4. 

Secondary. 




Crust 



Scale 



Excoriation 



Fissure 



"V" 



Ulcer 



Cicatrix 




Wheal 



Tumor 




1 Cutaneous Memoranda, Wood, 1ST. Y., 1885. 



36 GENERAL CONSIDERATIONS. 

Primary Lesions. A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from a pin-point to the palm of the hand, or larger ; 
but these large-sized and diffused non-elevated lesions are 
usually spoken of as patches. It may be white, red, brown, 
black, blue, pink, or yellow, according to its cause. It may 
be due to hyperemia, as in erythema simplex ; to a change 
in the pigmentation of the skin, as in lentigo and chloasma, 
where there is increase of pigmentation, or in vitiligo, where 
there is decrease of pigmentation ; to a hemorrhage into the 
skin, as in purpura; to a development of bloodvessels in 
the skin, as in naevus vascularis and telangiectasis ; to a 
parasitic growth in the skin, as in chromophytosis ; or a 
change in the consistency of the skin, as in morphoea and 
xanthoma. 

The macule may be evanescent or permanent; may re- 
main as a macule during its existence, or may give place to 
a papule, vesicle, or pustule. It is the simplest of all the 
lesions of the skin, and is met with as a primary lesion of 
many of its diseases. 

The principal macular diseases are chloasma, erythema 
simplex, lentigo, morphoea, nsevus simplex and spilus, pur- 
pura, scleroderma, chromophytosis, vitiligo, xanthoma, and 
melasma. 

A papule is a circumscribed, solid elevation of the skin. 
In size it varies from that of a pin-point to that of a split- 
pea. It may be of different colors, but is usually some 
shade of red. It is firm to the touch. In form it 
may be acuminated, rounded, flattened, umbilicated, or 
angular. It may be due to inflammation, as in eczema ; 
to a hypertrophy of normal structures, as in verruca; to 
the heaping up of epidermic cells about a hair follicle, as 
in keratosis pilaris ; or to the retention of sebaceous matter 
in a follicle, as in comedo and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed ; or it may change into a vesicle or 
pustule ; or it may soften and break down. 

Papular diseases have received the name of lichenoid dis- 
eases, and at one time we had a goodly number of lichens. 



DIAGNOSIS. 37 

Most of these have now been placed under other headings, 
as it is recognized that they are but single manifestations of 
other diseases. Papular diseases are apt to be scaly and 
itchy. 

The principal papular diseases are : lichen tropicus, lichen 
ruber acuminatus and planus, lichen scrofulosorum, lichen 
pilaris or keratosis pilaris, lichen urticatus or papular urti- 
caria, acne, comedo, milium, prurigo, and psoriasis. Like 
the macule, the papule is found in many diseases that cannot 
be classed as papular. 

A tubercle may be thought of as a large papule. Like 
it, it is a circumscribed solid elevation of the skin. Indeed, 
the diiference between a papule and a tubercle is mainly 
arbitrary and for convenience. Thus, we speak of a solid 
lesion up to the size of a split-pea as a papule, while above 
that it is spoken of as a tubercle. Quite commonly, when 
a lesion is larger than a cherry it is spoken of as a node. 
Auspitz 1 makes the distinction between a papule and tubercle 
on more scientific grounds, and regards a tubercle as a cell 
infiltration into the corium. A tubercle is not only larger 
than a papule, but it extends deeper into the skin. In form 
and color a tubercle corresponds to a papule. 

Tubercles may be absorbed and disappear and leave no 
trace ; or they may break down and ulcerate and leave 
scars, as in syphilis ; or they may remain unchanged for an 
indefinite period, as in molluscum. 

The principal tubercular diseases are : carbuncle, epithe- 
lioma, keloid, lupus vulgaris, molluscum, rhinoscleroma, 
and xanthoma. They form a very prominent symptom in 
leprosy, syphilis, and erythema multiforme. Of course, 
tubercular used in this sense has nothing to do with true 
tuberculous processes. 

A vesicle is a circumscribed elevation of the epidermis 
that contains fluid, mostly serous. In size it varies from a 
pinhead to a split- pea. Its color is crystalline when only 
serum is present ; more or less opaque and yellowish when 
the serum is mixed with pus, and of a reddish hue when 

1 Ziemssen's Handbuch der Hautkrankheiten. 



38 GENERAL CONSIDERATIONS. 

blood is effused into it. It may be pointed, rounded, flat- 
tened, or umbilicated. Vesicles are in most cases due to 
inflammation, as in eczema. They may be due to simple 
serous infusion, as in erythema ; or to the retention of 
sweat, as in sudamina. They have around them, in many 
cases, a red halo. As a rule, vesicles are superficial eleva- 
tions of the epidermis, and readily rupture and pour out 
their contents upon the skin, forming a yellowish crust. 
They may be below the mucous layer of the skin. They 
may remain as vesicles, and dry up, their contents being 
absorbed ; or they may become changed into pustules. 

The principal vesicular diseases are : eczema, herpes, 
sudamina, dysidrosis, dermatitis venenata, zoster, impetigo 
contagiosa, and varicella. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle. Its color is yellow and opaque ; or brown or 
reddish if there is an admixture of blood with the pus. It 
either originates as a pustule, or develops from a vesicle or 
papule. As a rule, pustules are inflammatory, and when 
they appear as a general eruption as in syphilis they indi- 
cate a strumous or broken-down condition. Around each 
pustule there is very commonly a well-marked inflammatory 
areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish or blackish crust. 
If located deep in the skin they may leave scars. 

The principal pustular diseases are acne vulgaris, im- 
petigo, ecthyma, sycosis, and furunculosus. 

A bulla may be considered as a large vesicle or pustule. 
It is of irregular oval shape or umbilicated. It may be as 
large as a split-pea, or reach the size of a goose-egg. It 
rises up from the skin with a slight areola or with none at 
all. It is either fully distended or flaccid, and does not 
rupture readily. It may be a bulla from the beginning, as 
we see in pemphigus, or it may be formed by the coalescence 
of two or more vesicles ; or it may form above an erythe- 
matous lesion, as in erythema multiforme. Its contents are 
usually serous, but this may give place in time to pus. 



DIAGNOSIS. 39 

The only purely bullous disease is pemphigus, but bullae 
are met with in dermatitis, dermatitis herpetiformis, ery- 
sipelas, and erythema multiforme. 

A wheal is an evanescent round, oval, or elongated flat 
elevation of the skin, of a pinkish or white color, which is 
more or less firm to the touch. It is surrounded by a red 
halo. It may be as small as a pea or as large as the palm 
of the hand. Wheals appear suddenly, and disappear within 
a few hours. They are due to a spasm of the capillaries and 
an effusion of serum into the meshes of the skin, the raised 
part being the site of the effused fluid, and the halo the 
congested vessels in the neighborhood. The disease in 
which wheals are met with is urticaria. They can also be 
produced by contact with the stinging nettle, or by sharp 
traumatism on skins predisposed to urticaria. 

A tumor is a new growth in the skin which projects more 
or less above its surface, and dips down into the subcutaneous 
tissues. It may be pedunculated. It is rather a surgical 
than a dermatological lesion. Epithelioma, fibroma, and 
sarcoma are types of tumors. They are met with also in 
syphilis and scrofula. 

Secondakt Lesions. The secondary lesions of the skin 
require a much less extended description. The main dis- 
tinction to be retained in the student's mind is that between 
a crust and a scale. This can be readily done if it is re- 
membered that a crust is formed by the drying of some 
secretion or exudation upon the skin ; while a scale is a dry, 
laminated mass of epidermis which has separated from the 
tissues below, the product of imperfect or perverted nutri- 
tion. Thus, in vesicular eczema when the exudation dries 
on the skin we have a yellowish crust ; while in squamous 
eczema we have thin scales, the horny layer of the skin not 
being perfectly produced. Crusts are light-yellow to dark- 
green or black in color, the latter indicating an admixture 
of blood. Scales are whitish, grayish, yellowish, or dirty 
yellow. 

Crusts are especially characteristic of ecthyma, some 
forms of eczema, impetigo, and seborrhoea. 



40 GENERAL CONSIDERATIONS. 

Scales are specially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ichthy- 
osis, and some of the lichens. 

Excoriations are familiar as scratch-marks. They are 
superficial denudations of the skin. They are of value as a 
sign of itching, as scratching is their chief though not sole 
cause. They frequently are followed by pigmentation, if 
the irritation causing the scratching is long-continued. 

Fissures are cracks in the epidermis extending down to 
the corium. They are usually located in the folds of the 
skin, as over the joints. They occur in diseases attended 
by infiltration and thickening of the skin by which its 
elasticity is interfered with, and are especially seen in 
eczema and syphilis. They often bleed, and sometimes are 
very painful. 

Ulcers are irregularly shaped and sized losses of sub- 
stance. They may be quite small, or of very large size. 
They may be shallow, deep, excavated, or scooped out. 
Their edges may be undermined, as in scrofula ; everted, as 
in epithelioma; or sharp-cut, " punched out," as in syphilis. 
Their secretion may be scanty or abundant. They result 
either from some previous lesion or from injury. They 
occur in epithelioma, chancre, chancroid, lupus vulgaris, 
syphilis, scrofula, varicose eczema, ecthyma, and sometimes 
after zoster, dermatitis, and some pustular eruptions. They 
always heal with a cicatrix, leaving a scar. 

Cicatrices, or scars, represent the effort of Nature to heal 
a damage to the skin by means of connective tissue. They 
only occur when the papillary layer of the skin or the parts 
beneath are destroyed. They may be depressed, as in small- 
pox ; raised and puckered, as in lupus ; smooth and white, 
as in syphilis. 

Other Elements of Diagnosis. Having mastered 
the lesions of the skin, we are now prepared to study 
the other elements of diagnosis. We must observe 
the location, distribution, and configuration of the erup- 
tion, and note its color and whether or not it itches. 
When we have done all this, and have come to a probable 






DIAGNOSIS. 41 

conclusion as to the disease before us, then is the proper 
time to ask the patient a few questions as to his sensations, 
and the duration of the attack. In a few cases of doubtful 
diagnosis, the microscope will aid us. 

Location. Upon the face we meet with acne, comedo, 
chloasma, erythematous eczema, epithelioma, herpes febrilis, 
lupus vulgaris, milium, rosacea, sycosis, and xanthoma. 

An eruption occupying the middle third of the face, fore- 
head, nose, and chin is in all probability rosacea. 

An eruption occupying the bearded portion of the face, 
above a line drawn from the angle of the mouth to the angle 
of the jaw, is probably sycosis. Should it occupy the 
bearded portion of the face below that line it is probably 
trichophytosis capitis. 

If a scaly patch is found in front of the ears it should put 
us on the lookout for psoriasis, which will often be found 
elsewhere on the body. This point may be useful in the 
diagnosis of a doubtful case. If a raw or cracked place is 
found behind the ears, it points to eczema. 

Upon the scalp we meet with pediculosis capitis, sebor- 
rhoea, trichophytosis, favus, alopecia, and alopecia areata. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape of the neck, we can be quite 
sure that the case is one of pediculosis, and if we look for 
the nits we shall find them either at the site of the eruption 
or over the parietal region. 

The chest is the favorite location for chromophytosis and 
keloid. 

Upon the back we meet with acne, carbuncle, and the 
scratch-marks due to the irritation from pediculi. If you 
find long, parallel scratch-marks over the shoulder-blades it 
is quite good evidence of pediculi in the clothing. 

The extensor surfaces of the forearms and wrists are the 
favorite sites of erythema multiforme. The elbow is affected 
with psoriasis ; while the flexor surfaces give lodgment to 
lichen planus and scabies, and the bend of the elbow to 
eczema. 

Upon the legs purpura, erythema exudativum, and ele- 
phantiasis are apt to occur. 



42 GENERAL CONSIDERATIONS. 

A general eruption is either one of the exanthematous 
fevers, or syphilis, psoriasis, dermatitis exfoliativa, pityriasis 
rubra pilaris, lichen ruber acuminatus, lichen planus, eczema, 
erythema, scabies, or ichthyosis. 

Of these, syphilis is most marked on the sides of the 
chest and abdomen, and upon the face along the margin of 
the hair. It may also be given as a general rule, to which 
there are many exceptions, that syphilis occupies the flexor 
surfaces of the arms and the anterior plane of the trunk, 
while psoriasis is found most markedly upon the extensor 
surfaces and the posterior plane of the trunk. 

Configuration. Certain diseases assume certain con- 
figurations, which, if noted, will sometimes assist in diag- 
nosis. Thus we have 

The circular outline and scalloped border of syphilis. 
The round and bald patch of trichophytosis and alopecia 
areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum, and 
the gumma of syphilis. 

The angular papules of lichen planus. 
The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis, and 
seborrhoea corporis. 

The patches of grouped vesicles upon reddened bases 
located over the course of a cutaneous nerve in zoster. 

Color. An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea of the 
color of an eruption, but perhaps this list may prove 
helpful : 

Raw ham of syphilis. 
Brilliant red of erysipelas. 
Inflammatorv red of eczema. 
Dark red of purpura. 
Bright red of psoriasis. 
Brown of pigmentary diseases. 
Sulphur yellow of favus. 
Buff of xanthoma. 



DIAGNOSIS. 43 

Violaceous or dull red of lichen planus and lupus 

erythematosus. 
White of leucoderma. 

Pruritus. It is important to know whether a disease 
itches or not. This we can discover by the presence or 
absence of scratched papules or scratch-marks. The itching 
eruptions are eczema, pruritus cutaneous, prurigo, urticaria, 
pediculosis, and scabies. The symptom is also present in 
the lichens, trichophytosis, seborrhoea, and psoriasis. It is 
markedly absent in syphilis, though an occasional case of 
syphilis will be encountered in which there is itching. 

History. Having carefully noted all these objective 
symptoms, we have by this time pretty well made up our 
minds as to the diagnosis of the case. Now is the time to 
obtain the history of the case, either for the purpose of 
scientific study of its etiology and natural course, or for the 
purpose of clearing up some doubt as to our diagnosis. It 
is so easy to obtain a history of syphilis, that were we influ- 
enced by the history, we would be often misled. There is 
no reason why a patient with syphilis should not have any 
other skin disease. Moreover, most people do not pay 
much attention to the history of their diseases, and it would 
be difficult for them to give a correct account of themselves, 
if they would. Of course, a clear history of the initial 
lesion of syphilis, or its presence, would clear up any doubt 
as to an erythematous rash. The history of a scaly disease 
recurring at frequent intervals upon the elbows and knees 
would go far to determine the existence of psoriasis. In 
urticaria we have to rely upon the statement of the patient 
or attendant as to the appearance of the wheals, as their 
presence at some time is pathognomonic, and they are usually 
absent when we see the patient. In these and similar ways 
the history is useful, but it should be entirely subordinated 
to the study of the objective symptoms. 

Burning. The sensation of burning is one the exist- 
ence of which we must take upon the patient's statement. 
It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches, but if you watch 
him, he will soon begin to gently rub his skin with the heel 



44 GENERAL CONSIDERATIONS. 

of his hand. This indicates that the sensation is one of 
burning and not of itching. In itching, the nails are used, 
or else the rubbing is vigorous. 

Pain. Another symptom for the establishment of which 
we have to rely upon the patient is that of pain. The vast 
majority of skin diseases, while they may cause more or less 
discomfort, are not painful. But sharp neuralgic pain is a 
prominent symptom in epithelioma and zoster. The pres- 
ence of pain of a shooting character will be one point in the 
differential diagnosis between lupus and epithelioma, and 
in favor of the latter. 

Microscope. The principal use of the microscope in the 
hands of the general practitioner is, as far as dermatological 
diagnosis is concerned, the determination of the presence or 
absence of fungi in hair and scales in a doubtful case of 
ringworm, favus, chromophytosis, or other parasitic disease. 
As a matter of fact it is very difficult to determine whether 
the mycelia and spores found in a hair are those of favus or 
of ringworm, unless the manifestations of the disease on the 
scalp are known and seen. Happily as between favus and 
ringworm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 

A few words must be said about the methods of examina- 
tion of patients. They should be always examined by day- 
light, or by electric light. It is prudent to refuse to give an 
opinion of a case when seen in a poor light, or by artificial 
light. If the patient is a man, it is but just to yourself to 
request him to strip from top to toe, if there is the slightest 
need of seeing more than the ordinarily exposed parts. In 
the case of a woman such a request should never be made. 
The same end can be attained by exposing one part after 
the other. By so doing you will have and merit the 
woman's respect and thanks. In all cases you are justified 
in refusing to treat a case that you have not been given 
ample opportunity to examine. 

All examinations of patients should be made in a warm 
room. The contact of cold with the usually covered skin 
is apt to give it a mottled look that obscures the diagnosis. 
It is well never to give a diagnosis of an obscure case that 



THERAPEUTIC NOTES. 45 

is under local or constitutional treatment, until all treatment 
has been suspended for a few clays and the disease allowed 
to assume its natural appearance. 

Every patient should be regarded as out of health in 
some way quite apart from his skin trouble, and examined 
as to the performance of all his functions quite as carefully 
as if he had come to you for the treatment of some internal 
disorder. 

Therapeutic Notes. 

In the second part of this book there will be found the 
treatment suitable to the various diseases. In this place my 
object is to give the reader a few notes upon some of the 
newer remedies for skin diseases. At present a new remedy 
is brought out nearly every month that promises to be better 
than any of its predecessors ; but careful comparative tests 
demonstrate that many of them are no better than the old 
and tried ones. It is better for the general practitioner to 
learn how to use a few drugs than to try every new thing. 
By practical experience he will be surprised to see how much 
he can accomplish with a very small assortment of drugs. 

The old-fashioned excipients for drugs for application to 
the skin were water, lard, and oils. Then vaseline and cosmo- 
line and other petroleum derivatives were taken up. These 
were all disagreeable to use because they were greasy. Then 
liquor gutta-perchce (traumaticin) and flexible collodion were 
introduced, and are still used. They are not greasy; they 
prevent the clothing from being soiled; give us a fixed dress- 
ing, and exert a certain amount of pressure upon the skin that 
is useful in some cases. They are most used in the treat- 
ment of psoriasis, ringworm, and in circumscribed chronic 
diseases. In acute diseases, and specially where there is 
more or less exudation, they cannot be used. 

Pastes answer admirably for these acute and exudative 
conditions, as they protect the part, and at the same time 
allow the exudate to work up through them, and thus escape. 
Lassar's paste, composed of zinc oxide, starch, and vaseline, 
as set forth in the formulary at the end of this book, was one 



46 GENERAL CONSIDERATIONS. 

of the first of these, and is still probably more used than any 
of them. Various other pastes have been proposed. It is 
found that infusorial earth (Kieselguhr) added to any ointment 
in the proportion of 10 per cent, will form a good paste. 

Gelatin preparations, one of which is given in the form- 
ulary, were introduced as preferable to ointments, and many 
German and English authorities speak well of them. They 
are troublesome to apply because they have to be heated be- 
fore being used, and take a good deal of time to set. They 
have not become popular in this country. 

In 1891 two excellent excipients were brought to our 
notice : one that is made from gum tragacanth, and called 
Bassorin ; and one that is made from Irish moss, and 
called Plasment. They both sink well into the skin, leav- 
ing a protective film on it that can be readily removed with 
water. 

Medicated soaps, specially those containing an excess of 
fat, have been brought out in great variety during the past 
years, and possess certain virtues, though as a rule a soap is 
not the best vehicle for medication. They are cleanly; can 
be readily removed from the skin with water, and can be 
made to produce a greater or lesser effect according to 
whether the lather is allowed to remain or not. 

Under the name of oleum physeteris or chcenoceti, a spe- 
cies of whale-oil was recommended by Guldberg 1 as an excellent 
excipient. Oleic acid is another vehicle that possesses the 
virtue of penetrating the skin. Lanolin and agnine, de- 
rived from the wool fat, are among the newer greasy appli- 
cations that are supposed to penetrate the skin. This prop- 
erty of penetration is not a virtue in all cases by any means, 
as in very many of our cases we wish to provide merely 
protection. 

In the way of drugs of comparatively recent date we 
have : 

Anthrarobin, which was proposed as a substitute for 
chrysarobin, but is a weak preparation, and has not proved 
of special use. 

Aristol is a good dressing for ulcers used in the form of 

1 Monatshefte f. prakt. Dermat., 1890, x., No. 10. 



THERAPEUTIC NOTES. 47 

a powder. It is expensive, but a good substitute for iodo- 
form in some cases, as it is devoid of odor. I have made 
many comparative tests with it and older remedies in treat- 
ing ulcers, and have found in the great majority of cases 
that the old friends were the best. In 10 per cent, strength 
it has been commended in the treatment of psoriasis, ery- 
sipelas, hyperidrosis, eczema, acne, rosacea, and all sorts of 
ulcers. 

Creolin, in 1 to 5 per cent, solutions in water, is often 
useful in erysipelas, dermatitis, and as an antiseptic. It is 
very irritating to some skins. 

Dermatol, a subgallate of bismuth, is said not to cake, 
and not to be poisonous. It is used as a powder for fresh 
wounds, forming a crust under which healing takes place. 
For excoriations, intertrigo, and slightly moist eczema it is 
to be mixed with equal parts of starch. For large, irritable 
ulcers it may be used as an ointment of 10 per cent, 
strength. 

Europhene. An amorphous powder of yellow color and 
aromatic odor, containing 28 parts of iodine in 100. Insol- 
uble in water and glycerin ; readily soluble in ether, chloro- 
form, collodion, and traumaticin. Useful in venereal ulcers 
and mucous patches in pure powder or 2 to 5 per cent, oint- 
ment. Also in tertiary syphilis as hypodermic injections in 
the vicinity of the lesion, and in solution in oil. 

Fuchsine, and other aniline dyes, in 1 per cent, solution 
in water, is recommended as useful in ringworm, inoperative 
cancerous ulcers, erysipelas, and other local infectious dis- 
eases. 

Gallacetophenone, made by the action of acetic acid upon 
pyrogallol, was brought out in 1891 as remarkably efficient 
in the treatment of psoriasis. It may be used in 5 to 10 
per cent, strength in ointment or collodion, does not stain 
the clothing, and thus far has not proved poisonous. 

Hydroxylamine is poisonous when absorbed. It was 
commended for psoriasis, but cannot be used over large 
surfaces. It has been commended in lupus vulgaris and 
ringworm of the scalp and beard — a grain and a half of the 
hydrochloride being dissolved in an ounce and a half each 



48 GENERAL CONSIDERATIONS. 

of alcohol and glycerin. It has not gained popular 
favor. 

IcTithyol, especially the ammonio-sulphate, is useful, ac- 
cording to its introducer, Unna, and many others, both for 
external and internal use in rosacea, acne, eczema, urti- 
caria erythema, herpes, dermatitis herpetiformis, seborrhoea, 
furunculosis, erysipelas, psoriasis, sycosis, lupus, and some 
other dermatoses. By the mouth it is best exhibited in 
capsules, from three to fifteen drops being given during the 
day. Externally it is exhibited in solution in water, or in 
paste form, and in the strength of 2J to 10, 20, or 50 per 
cent. 

Oxynaphthoic acid is recommended by Schwimmer for 
scabies and prurigo in 10 per cent, strength in ointment. 
His ointment for scabies is composed of ten parts each 
of the acid, chalk, and green soap, to eighty or one hun- 
dred parts of lard. 

Resorcin is recommended for seborrhoea capitis, be- 
ginning in 2 per cent, strength, and increasing up to 5 or 
10 per cent., as the acute stage lessens ; for psoriasis, 10 to 20 
per cent. ; eczema about the mouth, 2 per cent. ; erysipelas ; 
and as a plaster for keloid and malignant growths. Strong 
preparations, say 20 to 30 per cent., can be used in acne 
and rosacea for the purpose of producing a dermatitis, to 
be followed by peeling off of the old skin. 

Salol, two parts to one of starch, is commended for use 
in ulcers. 

Thilanin is lanolin acted on by sulphur, and containing 
3 per cent, of the latter. Recommended for acute and 
chronic eczema. 

Thiol, which is miscible with water, and is used in the 
strength of 20 per cent, in liquid or powder form, is said to 
be useful in seborrhoea, rosacea, acne, eczema, burns, pem- 
phigus, dermatitis herpetiformis, impetigo, and zoster. 

Tumenol. Used in solution with equal parts of ether, 
alcohol, and water, or glycerin, or in form of paste, or oint- 
ment. Useful in moist eczema, burns, ulcers, and rha- 
gades. 



some dermatological don'ts. 49 

Classification. 

In the present state of our knowledge it is impossible to 
make a satisfactory classification of skin diseases. Many 
attempts have been made to do this, and are still being 
made. Nearly every systematic writer tries his hand at it 
with more or less indifferent success. The most scholarly 
classification is that by Prof. E. B. Bronson {Journ. Cutan. 
and Gren.-Urin. Dis., 1887, v. 369), which is founded on 
that of Auspitz. Hebra's classification modified is found 
in a great many text-books. The arrangement of this book 
does away with classification, with which the student need 
not burden his mind. 

Some Dermatological Don'ts. 

Don't make your diagnosis from the history of a case, 
because if you do you will often be led astray. Make it 
from the eruption that you see, and then substantiate or 
destroy this by the history of the case, if you will. 

Don't fail to think of the possibility of every case being 
either syphilis or eczema ; and 

Don't fail to master these two diseases as thoroughly as 
possible ; because, if you learn to recognize these two, you 
will have gone a long way in diagnosis. If they can be 
excluded, then the field of possible " might be's " is consid- 
erably narrowed. 

Don't make the diagnosis of syphilis on account of a 
syphilitic history, because you can often get a history of 
syphilis in a non-syphilitic case. 

Don't expect much, if any, history of syphilis in a 
woman, because you very frequently will not get it. This 
is not because they are "gay deceivers," but because in 
them the early symptoms of the disease are often so slight 
that they are not observed by them. 

Don't throw out the diagnosis of syphilis on account of 
an eruption itching, because some syphilides, especially the 

3 



50 GENERAL CONSIDERATIONS. 

papular variety, do itch at times. The not itching of an 
eruption is better presumptive evidence of syphilis than is 
itching positive evidence against it. 

Don't make the diagnosis of lichen planus from the pres- 
ence of flat angular papules with depressed centres alone, 
because identical lesions will at times be met with in 
eczema, syphilis, and psoriasis. 

Don't depend upon getting the bleeding-points springing 
out of the delicate pellicle after carefully scraping off the 
scales for your diagnosis of psoriasis, because you can pro- 
duce the same thing in other diseases. In fact, 

Don't depend upon any one symptom, but make your 
diagnosis from the general make-up of the disease as a 
whole. 

Don't forget that many diseases of the skin are depen- 
dent upon disturbances in the general health of the patient. 
Therefore, 

Don't fail to inquire into the performance of the functions 
of the various organs of the patient, and to put him into as 
good a physical condition as possible. 

Don't tell your patient that it is dangerous to cure his 
skin disease rapidly, because it is not. If you 

Don't know how to treat the case, ask advice of someone 
who does. 

Don't encourage the popular notion that there is danger 
of an eruption striking in, because it never does. 

Don't give arsenic for every skin disease, and, especially, 

Don't give it in acute eruptions. Its sphere is in the 
chronic scaly eruptions, such as chronic psoriasis. 

Don't forget that most cases of pruritus are due to in- 
ternal causes, and that in them external treatment is wasted ; 
and 

Don't forget the bed-bug and the pediculus as possible 
causes of the trouble. 

Don't forget that the greatest secret in the treatment of 
eczema, and many other skin diseases, is not what particu- 
lar drug or formula is " good for " the disease, but a knowl- 
edge of the great principle that acute diseases need soothing 



SOME DERMATOLOGICAL DON'TS. 51 

remedies, and subacute and chronic diseases need stimula- 
tion. 

Don't expect to cure an inveterate eczema with thickened 
skin by means of a soothing ointment, such as that of the 
oxide of zinc, because you will only waste your time and 
the patient's money. 

Don't use tar in an acute eczema, because it is a stimu- 
lant, and what we want at this time is to soothe the in- 
flamed skin. It is appropriate to a subacute or chronic 
case. 

Don't allow water to touch any form of eczema, because 
it always irritates in such a case. 

Don't use a thick ointment on the hairy scalp, because 
it makes a disagreeable mess of the hair, and will not be 
" popular " with your patient. Even lard is not a pleasant 
vehicle for such applications. Vaseline and the oils are 
more elegant excipients. 

Don't order the hair to.be cut from the head of a young 
or old woman in any disease of the scalp, because, except 
in the case of a peculiarly stupid or careless patient, it is 
never necessary, and always disagreeable to the woman. 

Don't allow a patient with ringworm to go to school, be- 
cause if you do you will be responsible for the spread of the 
disease. 

Don't pronounce a ringworm case well and incapable of 
spreading the contagion until you are sure that it is well ; 
and 

Don't be sure about it until there are no more " stumps " 
on the scalp, and you can find no more of the fungus in 
the hair. 

Don't use the name "barber's itch" for anything but 
trichophytosis barbae, because it is well not to use terms 
loosely to cover several different diseases. 

Don't use chrysarobin on the face or scalp, because it 
is very apt to cause a good deal of dermatitis with oedema, 
and to stain the skin a deep mahogany-red. 

Don't forget to caution a patient to whom you have given 
chrysarobin, not to touch his face with his hands after 



52 GENERAL CONSIDERATIONS. 

applying the drug, because if you do you will have either a 
mad or a frightened patient in your office. 

Don't pronounce a patient addicted to the excessive use 
of alcoholic beverages on account of his having rosacea, be- 
cause there are lots of other things besides alcohol that will 
cause it. 

Don't use the positive pole of the battery for the needle 
in destroying hair by electrolysis, because if you do you will 
leave more or less permanent marks in the skin. 

Don't apply a sulphur preparation after using a mercurial 
upon the face, or vice versa, because if you do you will 
raise a fine crop of comedones. 

Don't use a camel's-hair brush for making applications 
of corrosive sublimate, because if you do some of the salt 
will be left on the brush each time it is used, and you will 
soon have a stronger solution than you bargained for. Al- 
ways use a little cotton on a wooden toothpick, or a splinter 
of wood. 

Don't allow a fine-toothed comb to be used on the 
scalp, because it scratches and irritates the scalp. 

Don't encourage or advise the use of pomades on the 
healthy scalp, because they are prone to become rancid, 
and inflame the scalp. They are also unnecessary if the 
hygiene of the scalp is properly looked after. 

Don't forget that dandruff is the most frequent cause of 
premature baldness, because if you remember this, you may 
be able to prevent the fall of someone's hair for some time. 
Therefore, 

Don't fail to treat every case of dandruff. — The Medical 
Record, December 29, 1838. 



PAET II. 

THE DISEASES OF THE SKIN AND THEIR 
TREATMENT. 



Scheme oe Pronunciation. 

A, ape ; A 2 , at ; A 3 , ah ; A 4 , all ; Ch, chin ; Ch 2 , loch (Scottish) ; E, he ; 
E 2 , ell ; G, go ; I, die ; I 2 , in ; N, in ; N 2 , tank ; O, no ; O 2 , not ; 
O 3 , whole ; Th, thin ; Th 2 , the ; U, like oo in too ; IP, blue ; U 3 , 
lull; U 4 , full; U 5 , urn; U 6 , like ii (German). 1 



Abscess (AV-se 2 s). 

Symptoms. Abscesses are very frequently met with as 
complications of diseases of the skin, such as acne, eczema, 
scabies, pediculosis, and other acute dermatitides. As thus 
met with, they are usually of small size, though at times, as 
upon the scalp of a strumous child, they may attain con- 
siderable dimensions. Their most frequent locations are : 
upon the scalp with eczema ; upon the face and back with 
acne ; and upon the extremities with scabies and pediculosis. 
Apart from a slight amount of discomfort, they do not give 
rise to subjective symptoms as a rule, and are indeed trivial 
affections. Of course, this does not apply to abscesses as 
seen by the surgeon. They may open of themselves and 
discharge their contents upon the skin. More commonly 
they are very sluggish in their course, and must be evacuated 
by some surgical procedure. 

Diagnosis. An abscess differs from a furuncle by not 
being raised, not having a central core, and by being less 

1 From Foster's "Illustrated Encyclopaedic Medical Dictionary," 
New York, 1890. By permission. 



54 DISEASES OF THE SKIN. 

firm to the touch. It differs from a carbuncle by an entire 
absence of marked constitutional disturbance, brawn y in- 
filtration, intense inflammation, and cribriform mode of open- 
ing. Kerion often resembles an abscess, but differs from it 
in its uneven surface and the welling up of a mucoid fluid 
alongside of the hairs. Syphilitic gwnmata are sometimes 
mistaken for abscesses and opened. They may be recognized 
by their dark -red color, their absence of pain and discom- 
fort, and the history of their growth. They grow slowly, 
beginning below the skin. There are generally more than 
one present, and then they are grouped. The aspiration of 
the tumor will decide the question. From an abscess we 
would obtain pus ; from a gumma a little bloody fluid. 

Treatment. The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, and 
the part dressed with carbolized vaseline if small, or anti- 
septically if larger. It is sometimes necessary to swab out 
the cavity with a strong carbolic acid solution to destroy the 
abscess wall and prevent the re-formation of the abscess. 

Absces Tuberiformis. See Inflammation of sweat glands. 

Abschilferung (A 3 b / -shi 2 l-fe 2 r-ung). Branny scaling of 
skin. 

Abschuppung (A 3 b r -shup-pung). Scaling or chapping. 

Acantholysis (A 2 k-a 2 n-tho 2 l'-i 2 -si 2 s). A disease character- 
ized by loosening or separation of the mucous layer of the 
epidermis. 

Acanthosis (A^-a^-tho'-s^s). A disease of the mucous 
layer of the skin. 

Acne (A 2 k'-ne). Synonyms: Varus, Ion thus; (Gf-er.) Fin- 
nen; (Fr.) Acn6, Bouton ; Stone-pock, Whelk, Pimple. 

Acne is an inflammatory disease of the sebaceous glands 
and the hair follicles, due to the retention of sebum ; char- 
acterized by an eruption of papules, pustules, or tubercles 
upon the face, neck, shoulders, or chest ; which usually 
begins at puberty, and tends to run a chronic course. 

Different writers and teachers have applied different 



ACNE. 55 

names to the different phases of acne. These had best be 
forgotten, except in so far as they are of historical value. 
The term acne is applied by the French school to all diseases 
of the sebaceous glands. It would seem to be the wiser 
plan to reserve the name for the disease just defined. Re- 
garded thus, we have but two varieties of true acne, and 
those are acne vulgaris and acne indurata. 

Acne Vulgaris or Simplex is either papular or pustular 
in character, though usually it is a combination of the two, 
together with more or less comedones scattered about. 

Symptoms. If only papules exist (A. papulosa), the face, 
shoulders, or chest will be found to be dotted more or less pro- 
fusely with pinhead-sized, acuminated elevations of the skin, 
of a pinkish to red color, and with a central opening at the 
summit. Very often the central openings will be filled by 
blackish specks. The lesions are then spoken of as A. 
punctata. This term is used by some writers to designate 
the comedo, but improperly, according to our definition. 
It is rare that acne exists only in the papular form. More 
usually it will be found that here and there the papules are 
surmounted by a pustule, or a pustule has taken the place 
of a papule. We now have A. pustulosa. In strumous 
subjects the pustular element preponderates over the papu- 
lar, and the face may be greatly disfigured by the large 
number of the lesions present upon it. The pustules are 
from pinhead to small pea size, and have an inflamed base. 

Together with the acne and the comedones, we meet with 
milia quite commonly, and the affected parts are usually 
greasy to the feel, showing that the sebaceous glands sym- 
pathize in the disease. We now have a fair picture of a 
typical case of acne vulgaris. The face, back, neck, or 
chest, or all four, are dotted over in an irregular manner 
with blackish points, papules, and small pustules ; the skin 
of the nose and forehead looks shiny and feels greasy, and 
perhaps there are some milia scattered about the region of 
the eyes. At times the face will look inflamed and hyper- 
aemic, especially in young, otherwise robust, subjects. More 
commonly the complexion will have that pasty appearance 
indicative of what has from old times been called the 



56 



DISEASES OF THE SKIN, 



strumous condition. If the inflammatory process has been 
unusually severe, we may find a considerable amount of 
scarring. Usually acne vulgaris does not leave scars. The 
profuseness of the eruption varies greatly. In some cases 
there will be but a few lesions, while in other cases they 
will be present in vast amount. This form of acne gener- 
ally occurs in young people. The duration of the individual 

Fig. 5. 




Acne indurata of the back. 



lesion is short, as it soon either dries up or discharges its 
contents. If the papules are squeezed, little plugs of se- 
baceous matter will be expressed. If the papulo-pustules 
are treated in the same way, there will first be pressed out 
a small sebaceous plug, and then a drop or two of pus. 

Acne Indurata is a pustular acne, in which the pustules 
are of large size, and seated upon deeply infiltrated bases. 

They are most commonly sparsely dispersed, and take 



ACNE. 57 

the form of purplish "lumps" of pea to bean size, which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch than by sight, being located deeply in 
the skin. Sometimes they take the form of cutaneous ab- 
scesses, and if by chance several are located close to one 
another, they may run together and form a raised, dark- 
red, doughy mass. When incised, these lesions sometimes 
give exit to a large amount of thick pus. They usually 
leave scars, which sometimes are very disfiguring, unless 
they are opened very early in their course. They may be 
the only form of acne present, or they may be combined 
with acne vulgaris. This form of acne usually occurs at a 
more advanced age than does acne vulgaris, though it is not 
infrequently met with in early life. 

Etiology. Acne is one of the most common of skin dis- 
eases, and its great predisposing cause is youth. The dis- 
ease first shows itself about the time of puberty, and 
manifests a tendency to disappear when the body is fully 
developed — that is, from the twenty-third to thirtieth year. 
A few rare cases have been reported of acne at an early 
age. Thus, Chambard 1 has met with a case in a girl of six 
and a half years. The indurated form of acne appears later 
than the simple form, usually after the twenty-fifth year. 
Both sexes are affected, but the disease is more frequent in 
females than in males, and in them begins at an earlier age. 
The period of youth is the time of great developmental 
activity in which the .sebaceous glands take part, and it is 
probable that there is a too great activity of the glands, and 
an improperly formed sebum is the result. Normally, the 
product of the fat glands is an oily fat. In acne an inspis- 
sation of the fat takes place, forming a plug that acts as a 
foreign body and sets up an inflammation. 

Individuals with thick, pasty, pale skins, with patulous 
follicular mouths, are predisposed to acne. These peculiarities 
of skin are met with in scrofulous subjects. The patulous 
follicular mouths give ready lodgment to foreign matters, 

1 Anna!. Derm, et Syph., 1878-9, x. 259. 



58 DISEASES OF THE SKIN. 

and comedones are thus formed. This prevents the escape 
of the follicular contents, a plug is formed, and we have an 
acne papule or pustule. Comedones are, therefore, an 
exciting cause of acne. 

Heredity has been asserted by some to be a predisposing 
cause of acne, but the disease is so common that there is no 
certainty about this factor. 

Of the exciting causes of acne, the most active one is 
some form of digestive disturbance. This may take the 
form of dyspepsia, stomachal or intestinal ; or it may be 
mal-assimilation ; or it may be failure on the part of the 
liver or pancreas to perform its physiological functions; or 
it may be sluggishness of the large intestine and consequent 
constipation. 

Next to disorders of the digestive organs, those of the 
sexual organs are supposed to have most influence in pro- 
ducing acne. But, inasmuch as most cases of acne are 
amenable to the influence of diet and regulation of diges- 
tive disorders without any attention being given to sexual 
disorders, it is probable that the latter are important etio- 
logical factors in comparatively few cases. Indeed, it is 
not improbable that the acne that appears on the faces of 
women at each menstrual period, and at that time alone, as 
well as the aggravation of an already existing acne, is due 
to the more or less pronounced disturbance of the digestive 
organs so frequently observed at the same time. In some 
cases acne does seem to be a reflex irritation from the 
uterus. Amenorrhoea is the uterine derangement most fre- 
quently encountered, but that condition is but one evidence 
of a general constitutional disorder, rather than a disease in 
itself. 

Masturbation and continence have each been blamed as 
excitants of acne. The former of these of itself does not 
cause acne, but its well-known effects on the nervous, moral, 
and physical condition of growing youths would sufficiently 
account for any part it may have in producing acne. There 
is absolutely no proof that continence causes acne. If a 
boy or young man keeps himself in a constant state of 
unrest by lascivious thoughts, that is not true continence, 



ACNE. 59 

even though he does not masturbate or copulate. It is safer 
for us to say that bad sexual hygiene may cause acne, 
rather than to ascribe it either to masturbation on the one 
hand, or continence on the other. 

It may be stated, as a broad general rule, that anything 
that lowers the general health of the patient contributes to 
the production of acne. We have space only to enumerate 
some of these exciting causes. Thus, we have the vague 
state, "general debility," anaemia and chlorosis, oxaluria 
and uraemia, rheumatism and gout, poor circulation, mental 
and physical exhaustion, and chronic malaria. 

In 1881 Denslow 1 advanced the theory that a want of 
tone in the arrectores pilorum muscles, either alone or to- 
gether with an over-production of sebaceous matter, and its 
retention in the sebaceous glands, was an important etiologi- 
cal factor in acne. As the muscles failed to act with suffi- 
cient vigor they did not perform one of their offices — the 
emptying of the follicles — and this allowed of the retention 
of glandular products and consequent acne. 

Since the rise of the present dynasty of microorganisms 
a great number of skin diseases have been declared to be 
parasitic. Acne of the pustular variety is one of these, and 
we are told that the pustule is due to the entrance of the 
staphylococcus aureus et albus into the follicles which offer 
proper ground for its growth. 

Pathology. Acne mav begin in the hair follicle or in 
the sebaceous gland, and may be due either to their becom- 
ing clogged up by inspissated sebum and acting like a thorn 
in the flesh, or to their invasion by microorganisms which 
set up a suppurative perifolliculitis. The papules of acne 
are located in the upper part of the skin, while the pustules 
are deeper. In very bad cases the follicle may be entirely 
destroyed by the perifolliculitis, and scars will be left. The 
sebaceous glands do not take a very active part in the pro- 
cess. 

In acne indurata we find the hair follicle enormously 
dilated, its orifice filled with corneous cells, and its cavity 

1 Xew York Med. Journ., 1881, xxxiii. 189. 



60 DISEASES OF THE SKIN. 

almost converted into a cyst. The connective tissue about 
the follicle shows decided signs of inflammation, and may be 
increased in amount. Very often the follicle is destroyed 
by the perifollicular inflammation. When the perifollicu- 
litis is severe and extensive, the deep layers of the skin be- 
come involved and we have abscess formation. 

Diagnosis. Acne is to be differentiated from rosacea, 
papular and pustular eczema, sycosis, the small pustular 
and tubercular syphiloderm, and variola. 

Rosacea is due to a dilatation of the bloodvessels, and is 
attended by hyperemia and telangiectases. If there are 
any pustules they are superficial, and if excised give exit to 
only a drop of pus. Acne is a disease of the sebaceous 
glands, and papules and pustules constitute the disease. 
They are often large, and if excised will give exit to a plug 
of sebaceous matter and thick pus. Rosacea, as a rule, 
occupies the middle third of the face alone, the forehead, 
nose, and chin. Acne is scattered over the whole face, and 
is often found on the shoulders. 

Papular eczema may occur at any age ; acne usually 
occurs between the ages of fifteen and twenty-five. Papular 
eczema rarely is seen on the face alone, and is prone to 
attack the trunk and extremities. Acne often occurs on 
the face alone, and is never disseminated over the limbs and 
trunk. In eczema there is an absence of comedones ; the 
papules are often surmounted by or change into vesicles ; 
they tend to form patches, and the disease is very itchy, so 
that scratch-marks are almost invariably found. When it 
gets well it leaves no trace on the skin. These symptoms 
are foreign to acne. 

In pustular eczema or what has been called impetigo 
simplex, we have a large number of small pustules running 
together to form patches which rapidly become covered with 
greenish or yellow crusts. The disease runs a far more 
acute and stormy course than does acne, and is itchy. It is 
very frequently met with in children, whom acne rarely 
affects. 

Sycosis is a pustular disease affecting the hair follicles 



ACNE. 61 

alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudimentary 
hairs. 

The small pustular syphiloderm, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain other 
evidences of syphilis, such as the remains of the initial lesion, 
enlarged lymphatic glands, mucous patches, or the like. It is 
usually more uniform in its lesions, and these are plainly 
papulo-pustular. The color of the areola is more that of raw 
ham, and less inflammatory-looking than is that of acne. The 
lesions sometimes show a tendency to group into segments of 
circles, and each lesion undergoes a definite development. 
They sometimes leave small, smooth, white scars that may dis- 
appear in a few months. The tubercular syphiloderm could 
be mistaken for an indurated acne. In it there will usually 
be found other evidences of syphilis. The lesions group 
themselves into patches that are kidney-shaped or form 
segments of circles. The tubercles are dark-red or raw-ham 
colored, surrounded by a well-marked areola, firm to the 
touch, and do not contain pus. They may ulcerate, or, 
being absorbed, leave pigmented and punched-out cicatrices, 
and, finally, smooth white scars. The scars left by acne 
indurata are puckered and more disfiguring. 

Variola could scarcely give rise to much doubt, as it has 
well-marked constitutional symptoms, and its lesions undergo 
a definite and characteristic development. 

Treatment. In the treatment of acne we can obtain a 
cure most surely by attention to the general condition of the 
patient ; most rapidly by a combination of internal and local 
treatment. Of course, in cases where only a single pustule 
crops out, as in some women at each menstrual period, there 
is no need for any treatment. But such are not those that 
ask our aid. 

We therefore begin the treatment of a case by a careful 
inquiry into the general condition of the patient, and 
endeavor to regulate any, even the slightest, derangement 
of the internal organs. By so doing we may find no one 
of those conditions enumerated under the etiology of the 



62 DISEASES OF THE SKIN". 

affection, and the patient may consider himself as in the best 
condition. Further observation will probably reveal some 
deviation, though slight, from perfect health. The relief of 
constitutional disorders is conducted according to the prin- 
ciples of general medicine, and cannot be given here. 
Many of the cases require cod-liver oil and iron as general 
measures quite apart from any evident disease. This is 
seen in the sluggish cases occurring in strumous subjects 
with pasty skins. In plethoric subjects with a good deal of 
inflammation attending the acne, laxative agents, such as a 
tenth of a grain of calomel in tablet triturates, given three 
or four times a day will aid in a cure, quite aside from any 
constipation. 

Diet and hygiene are agents to be employed rather than 
drugs. It is impossible for us to lay down fixed principles 
of diet, and it is better to study each case by itself. The 
well-to-do are all prone to eat too much, and it is remarka- 
ble how rapidly acne will improve by reducing their diet to 
the simplest elements. In many of them a milk diet for a 
few days, provided milk agrees with them, will accomplish 
a marked benefit. It is a good rule to cut off from the 
dietary all pastry, cake, candy, sweets, hot breads and pan- 
cakes, greasy soups, articles fried in fat, rich gravies — in 
fact, all those things that are most apt to tempt the palate. 
Oatmeal is often cited as a cause of acne. Hot water before 
meals, a glass of fluid, either milk or water, at meals, and a 
glass of water two hours after meals is a good direction for the 
use of things to drink. Tea, coffee, malt liquors, sweet and 
heavy wines are to be avoided. Exercise must be insisted 
on, an hour or more a day being spent in walking, riding 
on horseback, rowing, or other out-door exercise. Daily 
bathing or dry rubbing will keep the skin in healthy condi- 
tion, and Turkish baths are often beneficial. 

Arsenic, sulphide of calcium, glycerin, and ergot are the 
drugs that are given by the mouth as curative in acne. 
Arsenic is the oldest and most honored of these. It is of 
use only in very chronic, sluggish cases, and the more 
papular the case the more useful the arsenic. It should be 
used as a last resort, not as the first. Fowler's solution is 



ACNE. 63 

the most frequently used preparation, in doses of from three 
drops three times a day, as an initial dose, gradually in- 
creased to fifteen or twenty drops or until the appearance of 
some symptom of poisoning. Piffard 1 recommends bromide 
of arsenic in the dose of yj-g- to -^ grain two or three times a 
day in rather acute cases of acne. A convenient method of 
administration is to make a one per cent, solution in alco- 
hol, and give one to two minims of that in a wineglassful of 
water. Should it cause gastric irritation the dose must be 
lessened. I have used this in a number of cases and with 
good results. The sulphide of calcium will be useful in 
many sluggish pustular cases. It should be given in small 
doses, from y^- to -^ grain, in gelatin-coated pills or fresh 
tablet triturates. One pill may be given four or five times 
a day until the tendency to pustulation is increased. It 
then should be discontinued until the exacerbation has sub- 
sided, when it should be again administered. Glycerin was 
advocated by Grubler 2 as a cure for acne, and is well spoken 
of by others. It must be given in doses of a teaspoonful 
three times a day increased to a tables poonful, and is of 
most use in strumous cases. Ergot, either the fluid extract 
in doses of half a drachm three times a day, or a correspond- 
ing amount of ergotin, has many advocates. 

Ghrysarobin, internally, has been recommended by Stoc- 
quart, 3 in the dose of one-sixth to one-half a grain ; and 
Sherwell 4 advocates the passage of the cold sound through 
the urethra of a young man suffering with acne. Small 
doses of the bichloride of mercury are sometimes curative 
where there is much infiltration. 

The objects of local treatment are to open up the pustules 
and papules and allow of the escape of their contents, to 
stimulate the skin to a more healthful action, and, accord- 
ing to the bacteriologists, to prevent further infection of the 
follicles by microorganisms. To attain the first two objects 
we may employ either a quick or a slow method ; to attain 

1 Journ. Cutan. and Yen. Dis., 1884, ii. 71. 

2 Journ. de Bruxelles, 1870. 

3 Annal. Derm, et Syph., 1884, v. 15. 

4 Journ. Cutan. and Ven. Dis., 1884, ii. 335. 



64 



DISEASES OF THE SKIN 



the last object we employ an antiparasitic. The best pre- 
ventive local treatment is to keep the skin clean and its 
nutrition good by the use of soap and water. 

The most efficient local treatment for nearly all cases of 
acne is to put the skin somewhat on the stretch, and scrape 
it somewhat roughly with a large and long, blunt dermal 
curette with a fenestrated blade (Fig. 6). This tears off all 
the tops of the lesions, presses out all the contents of the 

Fig. 6. 




Fox's ring curette. 

follicles, and stimulates the skin in a most vigorous manner. 
It is followed by some bleeding, which it is well to encour- 
age by the use of warm water. Deep pustules or cutaneous 
abscesses if not emptied by the curetting should be incised. 
All comedones should be squeezed out. The after-treatment 
consists in washing the face with warm water and soap, and 
dusting with corn starch, to which may be added oxide of 
zinc. The scraping is to be repeated two or three times a 
week. The procedure seems rough, but after the first scrap- 
ing the patients do not mind it much, and the result is the 

Fig. 7. 



Fox's acne lance and dermal curette. 



attainment of a smooth skin in a much shorter time than by 
any other method of treatment. With this plan we may use 
a sulphur ointment, a drachm to the ounce, to be applied 
twenty-four hours after the scraping, or a wash of bichloride 
of mercury, one-half grain to the ounce of dilute alcohol, to 
which may be added a little glycerin. Thus will we fulfil 
all three of the indications for treatment. 

The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. 7), and 
squeezing out every comedo. This is to be done once 



ACNE. 65 

or twice a week, and a sulphur preparation used between 
times. Very timid patients who will allow no surgical inter- 
ference may be treated according to the same principles by 
directing them to scrub their faces thoroughly once a day 
with green soap, or tincture of green soap, and leave the 
lather on. After a day or two of good scrubbing an amount 
of dermatitis will be excited sufficient to cause the old skin 
to peel off, while the tops of many of the lesions will have 
been torn off, and the skin will have been decidedly stimu- 
lated. Not until the skin has become scaly and feels tense 
to the patient should a soothing ointment be applied. 
Repeated applications of the soap frictions will slowly bring 
about improvement. Rubbing the face with fine sand or 
coarse corn-meal will do good, but is not so elegant. 

Massage to the skin, pinching it up and rolling it between 
the thumb and fingers does well in emptying the follicles and 
stimulating the circulation. The application of the galvanic 
current by means of the roller electrode, or by ordinary 
sponge electrodes, will in some sluggish cases prove helpful. 

A vast number of prescriptions have been written which 
are "good for acne," the majority of which contain sulphur 
in some form, and in the strength of half a drachm to one 
drachm to the ounce, and in ointment or lotion form, Sul- 
phur in powder form is good if the patient doesn't mind the 
odor. The ordinary sulphur ointment of the Pharmacopoeia 
diluted one-third or one-half is as good a preparation as 
any. It may be made more elegant by adding some perfume. 
The sulphuret of potassium may be used in the following : 

R. Potass, sulphurat., ) .. • . , 

Zinci sulphat., J ' ' «'«' ' 

Aquas rosse, 5 iv ; 120 M. 

This preparation is commonly spoken of as " Lotio alba," 
and is one of the most useful of the compounds of sulphur. 
It is to be applied every day after being well shaken. 

Vleminck's solution is an active preparation in causing 
the old skin to exfoliate. It is composed of — 



M. 



R • Calcis, 


3 ss ; 


15 


Sulph. sublim., 


3j; 


30 


Aqua? destil., 


3 x ; 


300 


Cook to ^ vj. and filter. 







66 DISEASES OF THE SKIN. 

After this has been left on a few hours, it must be washed 
off and a soothing ointment, such as ungt. zinci oxid., or 
ungt. aquae rosae, applied. It is most useful in acne of the 
back. 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It must be borne in 
mind that a mercurial must never be applied to the skin 
until all traces of sulphur are removed, or vice versa, 
because if the precaution is forgotten, the black sulphide of 
mercury will be formed, which will give the skin the appear- 
ance of being sown with powder-grains. A lotion of corro- 
sive sublimate, 1 in 1000 to 2000, may be mopped on once or 
twice a day. Or an ointment of the protiodide, as recom- 
mended by Duhring, may be used : 

R. Hydrarg. protiodid., gr. v-xv ; II 

Hydrarg. amnion., gr. x-xxx ; 2 

Ungt. simplicis, ^j ; 30 1 M. 

Lassar 1 recommends the following paste : 

R . /3-naphthol, 10 parts. 

Sulphur precip., 50 " 

Vaseline, \ 25 u M 

feapo vmdis, J 

This is to be spread upon the skin to the thickness of the 
back of a knife-blade, and left on for fifteen or twenty 
minutes. It is then to be wiped off with a soft cloth, and 
the skin powdered with talc. The skin becomes inflamed, 
turns brown, and peels off. The application is to be re- 
peated every day until the skin does peel off. Desquama- 
tion can be hastened by the application of Lassar's paste 
with two per cent of salicylic acid. 

Resorcin has been commended, used in twenty per cent, 
strength. Ichthyol, the ammonio- sulphate, is recommended 
by Unna for acne. As much as fifteen grains of it is to be 
taken by the mouth during the day. A mild corrosive sub- 
limate wash is to be applied to the face until the patient goes 
to bed, and then a ten per cent, aqueous solution, or paste 
of ichthyol, is to be kept on till morning. Startin 2 has em- 

1 Therap. Monatsnft., 1887, No. 1. 

2 Lancet, 1889, i. 934. 



ACNE. 67 

ployed local steam baths by means of a steam atomizer, with 
success. The steaming should be kept up for twenty or thirty 
minutes, and tincture of benzoin used in the medicine cup. 

The foregoing remedies are all specially adapted to more 
or less sluggish cases, the type met with in the great 
majority of instances. In very recent and quite inflamma- 
tory cases, besides the administration of laxatives and the 
regulation of the diet, the patient should be directed to 
bathe the face in hot water either with or without the addi- 
tion of borax (5ij to Oj), and apply a soothing ointment. 

Bathing of the face with hot water before the application 
of any lotion or ointment should be advised. In indurated 
acne, where cutaneous abscesses have formed, and the lesions 
are discrete, each abscess will have to be opened up with a 
lance, the contents of the abscess discharged, and carbolic 
acid, either pure or diluted, introduced, by means of a little 
cotton around the end of a bit of wood, into the abscess 
cavity, so as to destroy the lining membrane. 

Individual acne lesions can sometimes be aborted by touch- 
ing them with pure carbolic acid, or acid nitrate of mercury. 

Prognosis. By persistent effort, and careful regulation 
of all the bodily functions, a great improvement can be 
effected, one fairly deserving of the name of cure. But noth- 
ing can prevent the occasional appearance of a few acne 
lesions until the period of life in which acne usually occurs 
is passed. There are some rare cases in which we can do 
nothing, because we are unable to remove the underlying 
cause. 

Acne Albida. See Milium. 

Acne Artificialis. By this term is meant an inflam- 
mation of the sebaceous glands and hair follicles caused by 
drugs either applied locally or acting from within. It has 
three principal varieties, namely, tar acne, bromie acne, 
and iodic acne, and should be regarded rather as a derma- 
titis medicamentosa than as an acne. Tar produces acne- 
like lesions with black points when applied locally to some 
susceptible skins. As a rule, papules are more abundant 
than pustules, but abscesses and furuncles may form. These 
lesions are not confined to the usual locations for acne, are 



68 DISEASES OF THE SKIN. 

particularly abundant on the extensor surface of the arms, 
and are recognizable by their central black points, and by 
the fact that the patient is using tar. For its cure air that 
is necessary is to stop the use of the tar, and to sooth the 
inflamed skin. None of these acnes is a true acne. 
Bromic and iodic acne will be spoken of under Drug erup- 
tions. Derivatives of tar, chrysarobin, and pyrogallol may 
also produce similar acne-like lesions when applied ex- 
ternally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to. acne frontalis. The first needs no description. 
The other will be found further on. 

Acne Cachecticorum is rather to be regarded as a 
scrofuloderma than an acne, as it probably has little to do 
with the sebaceous glands. It occurs in broken down or 
scrofulous subjects, and is particularly prone to appear 
upon the extremities. It takes the form of small, con- 
gested, or dark-red, sluggish papules and papulo-pustules 
that run a slow course, break down, perhaps ulcerate, and 
leave small depressed cicatrices. Occurring on the fingers, 
these will often be congested and clubbed. It is one of the 
rare forms of disease and requires tonic remedies such as 
cod-liver oil and iron for its cure. 

Acne Cornea. See Psorospermosis follicularis. 

Acne Fluente. See Seborrhoea oleosa. 

Acne Frontalis. Synonyms : Acne rodens, a. ulcer- 
euse, a. atrophique, a. arthritique, a. miliare scrofuleuse, a. 
varioliformis of the Germans, a. necrotica, a. pilaris, 
lupoid acne. 

Acne frontalis is the name given by Boeck to an acne- 
form lesion that occurs in adults on the forehead along the 
line of the hair. It is also met with on the cheeks and 
nose, and some lesions may be on the scalp. It has been 
described as occurring upon the trunk, sternal region, and 
back. The eruption consists of pinhead- to lentil-sized, 
reddish-brown, hard papules, on which form flaccid pustules 
that soon dry into a brown crust. If on hairy regions the 
crust may be pierced by a hair. Some papules have an 



ACROCHORDON. 69 

inflammatory halo around them. The crust adheres very 
closely, and seems as if sunk into the papule. If removed 
a loss of substance is revealed. It is possible to press out 
a drop of pus from under old lesions just about ripe enough 
to lose their crusts. When the crust falls of itself it leaves 
a brownish- red cicatrix that gradually grows white. Some- 
times the lesions are present in large numbers, and as each 
one runs a slow course, lesions in all stages of development 
will be found. 

This is a rare form of disease, and its etiology and path- 
ology are still undetermined. It bears a decided resem- 
blance to syphilis m some of its forms. It is probable that 
some of the cases that have yielded to mercurial ointments 
were syphilitic. 

Treatment. In treatment sulphur ointment or a mer- 
curial will probably give the best result. 

Acne Hypertrophica. See Rosacea. 

Acne Keloidienne. See Dermatitis papillaris capillitii. 

Acne Mentagra. See Sycosis. 

Acne Miliaris. See Milium. 

Acne Rodens. See Acne frontalis. 

Acne Rosacea. See Rosacea. 

Acne Scrofulosorum. See Acne cachecticorum. 

Acne Sebacea. See Seborrhoea. 

Acne Syphilitica. See Pustular syphiloderm. 

Acne Tuberculoide, or Tuberculeuse Ombiliquee. See 
Molluscum contagiosum. 

Acne Varioliformis. See Molluscum contagiosum and 
Acne frontalis. 

Acrochordon (A 2 k-ro-ko 2 rd'-o 2 n). See Molluscum pen- 
dulum. The term is also applied to large or small 
polypoid prominences produced by an overgrowth of the 
endothelium of the sebaceous glands. These occur in 
elderly people upon the eyelids, neck, and throat. They 
may attain the size of hazel-nuts, and look like overgrown 
milia. The treatment consists in removing them by liga- 
ture or scissors. 



70 DISEASES OF THE SKIN. 

Acrodynia (A^-ro-drn'-P-a 3 ) is a disease closely allied 
to pellagra in its symptoms, that has been observed chiefly 
amongst the French and Belgian soldiers, and is probably 
due to some defect in food supplies. It begins with gastro- 
intestinal irritation to which certain neuroses soon add 
themselves, such as formication, hyperesthesia and anaes- 
thesia. An erythema of the hands and feet, and may be 
of the whole body, followed by brown or black pigamenta- 
tion, is the cutaneous element of the disease. Recovery 
usually takes place, though death may occur from diarrhoea. 

Addison's Keloid. See Morphcea. 

Adenoma (A 2 d-e 2 n-o r ma 3 ). These are glandular tumors, 
and are due to a proliferation of the lining cells of either 
the sebaceous or sweat glands. There are therefore two 
varieties : A. sebaceum, and A. sudoriferum. Though met 
with in persons of mature years it is not improbable that 
they are congenital defects. They form solid tumors from 
pinhead to egg size or larger. They may remain stationary 
or grow ; may disappear spontaneously, ulcerate, form cysts, 
or undergo hyaline, colloid, or fatty degeneration. While 
usually benign, they may become malignant. They tend to 
relapse after extirpation. 

The sebaceous form is encountered most often on the 
face, about the nose and mouth ; less frequently upon the 
scalp, but may occur anywhere. Their color varies from 
pale yellow to red, when they will have fine telangiectases 
over them. They occur most often in females, are generally 
multiple, often with an uneven surface, and seated deep in 
the skin. 

The sudoriferous variety occurs as dirty grayish-white 
tumors, sometimes in groups, with uneven, often knobby 
surface. They are rare lesions of the skin, difficult of 
diagnosis, and require extirpation or total destruction for 
their cure. 

Ainhum is a disease most frequently seen in the negro 
race, though a number of cases have been reported from 
India. It is seen in men more often than women, and 
several members of the same family have been known to be 



ALOPECIA. 71 

affected by it. The little toe, of one or both feet, is the one 
usually diseased, though the other toes do not always 
escape. It begins as a furrow on the inner and lower side 
of the proximal end of the toe, which gradually extends 
outward and upward so as to encircle the whole toe at its 
juncture with the foot. In the meantime the toe becomes 
enlarged, separates from its next neighbor, and rotates 
outward. When fully developed the toe wobbles about so 
that it interferes with walking. The whole process is un- 
attended with ulceration except accidentally caused, and 
after the disease has lasted a long time. When it sets in 
the toe falls off. There is little pain experienced till near 
the end of the disease. It takes from one to ten years for 
the full development of the disease. The cause is unknown. 
The process is one of progressive degeneration and destruc- 
tion of all the elements of the toe ; skin, muscles, bone. 
Amputation is required for the cure, and healing takes 
place rapidly. 

Albinism. See Leucoderma. 

Aleppo Boil, Aleppo bouton, or Aleppo evil, is an ill-de- 
fined furuncular disease occurring in Syria and the Levant. 

Algidite Progressive. See Sclerema neonatorum. 

Algor Progressivus. See Sclerema neonatorum. 

Alopecia (A^-o-pe'sh^-a 3 ). Synonyms : Calvities ; (Fr.) 
Alopecie; (Ger.) Kahlheit; (Ital.) Calvezza ; (Sp.) Calvez; 
Baldness. 

By alopecia is meant a partial or general loss of the hair, 
so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely, Alopecia adnata; 
Alopecia senilis ; Alopecia prematura or presenilis ; and 
Alopecia areata. 

Alopecia Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. The newborn child is covered with long 
dark hair which soon falls to give place to fine lanugo 
hairs ; or this change has taken place before birth, the usual 
course of events, and at birth lanugo hairs only are present. 
In alopecia adnata there is not the slighest trace even of 



72 DISEASES OF THE SKIN. 

lanugo hairs either on the scalp or eyebrows. In some 
cases the baldness is not so complete. Most cases, after 
months or years, recover either altogether or partially, but 
in some cases the hair never grows. In pronounced cases de- 
layed dentition or deficiency of the teeth have been observed. 

Etiology. The cause of the disease is arrest of the de- 
velopment of the hair, probably due to an error in innerva- 
tion. It is said to be hereditary in some families. 

Tkeatment. The treatment is mainly an expectant one. 
The nutrition of the child should be looked after, and the 
scalp kept in a healthy condition. If this expectant plan 
does not satisfy the child's attendants, some of the stimulat- 
ing hair washes, as in alopecia presenilis, may be prescribed 
for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing 
years. Any loss of hair commencing about the forty-fifth 
year and without any apparent cause may be placed under 
this heading. Graying of the hair may have preceded it 
for several years or may be coincident with it. Or the 
hair may fall without becoming gray. The hair fall 
having once begun is progressive, though its rate of progress 
may be slow or fast. It usually shows itself first upon the 
vertex of the head, forming the tonsure, which slowly in- 
creases in size, and, moving forward, renders the whole top 
of the head bald. Or it may begin anteriorly and move 
backward. Or the hair on the whole top of the head may 
become thinned at once. Rarely are the temporal and occi- 
pital regions bald, and an island or tuft of hair is sometimes 
preserved for a long time in the middle frontal region. 
The hair fall is always symmetrical, and the bare scalp is 
smooth, oily, shiny, and appears as if stretched. Not only 
does the hair fall from the scalp, but it may fall from the 
axillae and pubic region ; these manifestations I believe to 
be more common in women than men. Very rarely does 
the beard fall. 

Etiology. The cause of this form of baldness is a pro- 
gressive atrophy of the scalp. Men are far more prone to 
the disease than are women. 

Treatment. As to the treatment, we can do nothing. 



ALOPECIA. 73 

Prophylaxis, as described under Alopecia prematura, will 
delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia 'prematura idiopathiea arises without any evi- 
dent disease of the scalp or disorder of the general health. 
It usually begins in early life, between twenty-five and 
thirty-five ; it may begin as early as the eighteenth year. 
Its general course is the same as the senile form of alopecia. 
Very often the upper parts of the temples are earliest 
affected, the hair line receding. In those who part the hair 
in the middle, the thinning of the hair about the part may 
be the first thing to attract attention. The process of the 
hair fall is one of progressive thinning of the individual 
hairs at first, and then of the whole quantity of hair, so 
that strong hairs give place to lanugo hairs, and these in turn 
fall and leave bald places. At the same time a progressive 
tightening of the scalp upon the skull will be observable in 
some cases, the scalp having lost that cushion of fat that is 
under it in early life. The hair fall having begun is pro- 
gressive, though years may elapse before there is absolute 
baldness. The tonsure may not enlarge for a long time, 
and then increase rapidly in size. 

Etiology. The main cause of this form of baldness is 
heredity. Fathers and sons for generations may grow bald 
early, or the inherited peculiarity may have to be traced to 
the grandparents or some collateral line. Not all the 
children of one family in which baldness is hereditary are 
bald, but it will manifest itself in two or three of the chil- 
dren. According to Pincus, 1 inheritance and chronic eczema 
or an impetiginous eruption on the scalp in the years pre- 
ceding puberty are the only predisposing causes of bald- 
ness. Insufficient or improper care of the scalp ; daily 
sousing of the hair with water, combined with improper 
drying of the hair afterward ; sweating of the head, either 
spontaneously or on account of the wearing of unventilated 
or hot head-coverings ; constant mental strain, either on 

1 Yirchow's Archiv., 1867, xli. 322. 
4 



74 DISEASES OF THE SKIN. 

account of intellectual work or of worry ; the wearing of 
stiff, unyielding hats ; gout ; and dissipation, are all put 
forth by reputable observers as causes of premature baldness. 

That women are less often bald than men probably de- 
pends upon several factors : The fatty cushion beneath 
their scalps is longer preserved than in men ; they give more 
attention to the care of the hair and less often wet it ; and 
their hats are soft, ventilated, and fit loosely. 

Treatment. We can do more for this form of baldness 
by prophylaxis than by attempts at making the hair that 
has fallen out grow in again. Prophylaxis should begin at 
the beginning of life, and should be continuous. This is of 
special importance in the care of children in families prone 
to early loss of hair. 

The hygiene of the scalp is the chief part of the prophy- 
lactic treatment. Beginning at infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the process 
of parturition. This should be done by the gentle use of 
soap and water after rubbing in a little sweet almond or 
other bland oil. No force should be used, and after the 
scalp is washed it should be patted dry with a soft warm 
cloth, and a little oil or vaseline smeared over it. After 
the first washing it should be oiled daily and washed every 
second day. When the hair begins to grow a soft brush 
alone should be used to arrange it, and the daily oiling 
may be stopped unless sebaceous matter accumulates in 
cakes, in which event the oiling should be continued. 
Sometimes it is well to add a little sulphur to the oil or 
vaseline, but in most cases it is unnecessary. The slightest 
indication of disease of the scalp should be promptly and 
properly dealt with. A child's hair should be cut short, 
not cropped close to the head. After a girl has reached her 
eighth or ninth year, the hair should be allowed to grow. 

The hair and scalp do not need to be washed more than 
once in two or three weeks, and for this purpose any good 
soap will do, with plenty of water to wash out the soapsuds. 
Borax with water will clean the scalp nicely, but its con- 
tinuous use is injurious. The yolk of three eggs beaten up 



ALOPECIA. 75 

with lime-water makes an elegant shampoo. The daily sousing 
of the head in water should be prohibited. Deep brushing 
of the hair with a long-bristled brush of sufficient stiffness 
to warm, but not scratch the scalp, is the best agent we have 
for stimulating the scalp. The brushing should be done 
daily and systematically. 

Pomades and hair washes should be avoided unless there 
is some evident disease of the scalp. Women should be 
cautioned against pulling their hair into artificial and con- 
strained positions. Most important of all is it that a suf- 
ficient amount of outdoor exercise should be taken to aid in 
keeping the patient in good general condition. 

When the hair has begun to fall it is important that the 
hygiene of the scalp should be begun, if not already prac- 
tised. We can do more for our cases in this way than by 
any other method. 

Many remedies have been advised for the curative treat- 
ment of baldness. Pilocarpine, in hypodermic injections or 
in ointment form, has been warmly commended. Lassar 1 
prescribes it as follows : 

R. Hydrochlorate of pilocarpine, gr. xxx; 2| 

Vaseline, £v ; 20 j 

Lanolin, ^ij; 60 j 

Oil of lavender, gtt. xxv M. 

He also advises oil of turpentine, equal parts with an 
indifferent oil or alcohol. It is my experience that most of 
these cases do better with oily than with alcoholic prepara- 
tions. Gallic acid, 3 per cent., in an oily excipient ; tar ; 
galvanism ; massage ; tincture of cantharides (5j-oj) ', tinc- 
ture of nux vomica (5j— Sj) ; and a lot of other irritants and 
essential oils, have their advocates. 

Peognosis. But the prognosis of this form of baldness is 
bad, and especially so if the disease is hereditary and the 
patient is more than thirty years of age. It is better with 
women than with men, as they will give more time to the 
care of their scalps, and show less tendency to alopecia. 

Alopecia prematura symptomatica is premature bald- 

1 Therap. Monatsheft, 1888, No. 12. 



76 DISEASES OF THE SKIN. 

ness in which there is some evident disease of the scalp, or 
disorder of the general nutrition of the body, to account for 
it. It has four varieties : Alopecia furfuracea seu pity- 
rodes ; A. syphilitica ; Defluvium capillorum ; and A. fol- 
licularis. 

Alopecia Furfuracea seu Pityrodes is the form most 
frequently met with, and the one in which we can often 
obtain good results by treatment. 

Symptoms. In it we have an evident disease of the scalp 
to deal with — that is, dandruff. By this we mean either a 
seborrhoea with fatty crusts, or else a pityriasis with more 
or less abundant scaling. Unna regards both conditions as 
being simply different forms of one disease that he calls 
eczema seborrhoicum. 

Alopecia pityrodes has two stages : The first one lasts 
from two to seven years or more, and is attended by a 
greater or less amount of dandruff and by dryness of the 
hair. Then comes the second stage, when the hair falls 
more or less rapidly. Its course may be the same as that 
of the two previously described forms of baldness, though 
more commonly the whole top of the head is affected at 
once, the hair becoming progressively thinner in diameter 
and less in amount until baldness results. As the baldness 
increases the dandruff lessens. The disease is one of early 
life in a large number of cases, often occurring between the 
twentieth and thirtieth year, and affects both sexes. 

Etiology. The cause of the hair fall is the dandruff. By 
this it is not meant that everyone who has dandruff will 
become bald. Everyone's experience is against that. But 
it is true that in certain persons when, on account of some 
error in the nutrition of the sebaceous glands, they become 
diseased, the hair follicles sympathize with them, and after 
a time the hair production ceases. Of late, the opinion is 
gaining ground that alopecia pityrodes is contagious, and 
the experiments of Lassar and Bishop 1 would seem to prove 
this. They succeeded in producing typical alopecia pity- 
rodes in guinea-pigs by rubbing into their backs a pomade 

1 Monatshefte f. prakt. Dermat., 1882, i. 131. 



ALOPECIA. 77 

composed of the scales taken from the head of a student who 
was afflicted with the same disease. A number of observers 
have reported from time to time the finding of a parasite in 
this disease, but as yet no one microorganism can be demon- 
stated as positively at the bottom of the trouble. 

Treatment. The treatment of this form of baldness must 
be addressed to the cure of the seborrhoea or pityriasis that 
causes the loss of hair. Prophylaxis is here again more 
important than the use of remedies for promoting the growth 
of the hair. The treatment of seborrhoea and pityriasis 
will be considered under their respective headings, and need 
not be here detailed. My belief is that oily applications 
are better than those containing alcohol. The mistake is 
frequently made of prescribing tincture of cantharides or 
other irritant because the hair falls. Of course, these 
things, in an already more or less inflamed scalp, only do 
harm. If we can succeed in curing the seborrhoea, the hair 
will take care of itself. If the case comes to us before abso- 
lute baldness is established we can feel pretty confident that 
we can stop, or at least delay, the fall of the hair. 

Lassar's plan of treatment has gained great currency, 
and is as follows : The scalp is to be vigorously washed each 
day with a tar soap that forms plenty of suds. The soap- 
suds are to be washed out with warm, followed by cold 
water, the scalp dried and anointed with equal parts of a half 
per cent, solution of bichloride of mercury, glycerin, and 
cologne water. This is to be dried out by applying a half per 
cent, solution of /3-naphthol in absolute alcohol. Finally, 
an oil made up of 



& . Ac. salicylici, 3 iv ; 16 

Tincture of benzoin, gr. xl ; 3 

Neat's-foot oil, g iij ; 100 



M. 



is to be applied. The procedure is to be kept up for six to 
eight weeks. I have found few patients who would persist 
in it, and in these I have seen little good result. For 
women it is impracticable. 

Resorcin has been commended. It may be prescribed 
as follows : 



78 DISEASES OF THE SKIN. 

R . Resorcin pura, gr. xv ; 3 

01. ricini, % ss ; 6 

Spts. vini rect, ad %] ; 100 

Bals. Peruv., gtt. ij. M. 

Tar is a good remedy, but it is objectionable on account 
of its odor and color. /3-naphthol, in 5 to 10 per cent, 
strength, and hydrate of chloral in about the same strength, 
may be tried. When there is absolute baldness, it is ques- 
able if anything will make the hair grow. 

Alopecia Syphilitica may be an early or late manifesta- 
tion of syphilis ; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 
temporary hair fall, or as a localized, destructive, and per- 
manent one. 

Symptoms. The former variety occurs early in the dis- 
ease, and is a thinning of the hair in irregularly shaped 
patches scattered over the scalp, giving to it an appearance 
similar to what would be produced by cutting the hair care- 
lessly with a dull pair of shears. In rare cases we may 
have a general loss of hair from all hairy regions. The 
broken arch of the eyebrow is always suggestive of syphilis. 
There may be some seborrhcea with this form of alopecia. 

Localized baldness is one of the later manifestations of 
syphilis, and is always preceded by a destructive disease of 
the scalp. The bald spots will vary in size with the extent 
of the destructive process, which may be one of absorption 
or ulceration. 

Diagnosis. The diagnosis of syphilitic alopecia is made 
by observing the irregular shape of the patches, and that 
they are not completely bald ; and by the occurrence of the 
broken arch of the eyebrow. These should arouse suspicion, 
when other symptoms of the disease will be found. It most 
resembles alopecia areata, but in this disease the patches are 
perfectly circular or oval, and entirely bald. 

The baldness due to destructive forms of syphilis can be 
confounded only with that of favus. In the latter disease, 
the scalp preserves a reddish color for a long time, and then 
assumes an atrophic, smooth, cicatricial look which is char- 
acteristic of it. The history of the two cases is very dif- 



ALOPECIA. 79 

ferent, as in favus we do not have ulceration, and we do 
have cupped, sulphur-yellow crusts. Favus is also more 
widespread and disseminated than is late syphilis of the scalp. 

Treatment. The treatment of this form of baldness is 
that of the underlying disease. A mercurial ointment or 
an oil containing the bichloride may aid in hastening the 
new growth of the hair in the early form of baldness. The 
late form may be lessened by active constitutional and local 
treatment, according to the general principles laid down for 
the management of syphilis. 

The variety called Defluvium Capillorum is that sudden 
and general fall and manifest thinning of the hair which 
comes on during or after some severe illness, such as parturi- 
tion, fevers, mercurialism, and various cachexise. 

Symptoms. Rarely does it produce complete baldness. 
The fall is usually rapid, and takes place during convales- 
cence or after recovery, rather than during the course of the 
disease. Seborrhoea may or may not be present. 

Etiology. The cause of the hair fall is the profound dis- 
turbance of the nutrition of the body, in which the hair 
sympathizes. 

Treatment. The treatment is rather to be addressed to 
the patient than to the hair. If we can succeed in building 
up the patient's strength, the hair will take care of itself. 
Local treanment is the same as in alopecia pityrodes. 

Alopecia Follicularis is baldness due to some disease 
of the scalp that either destroys the hair follicles or impairs 
the proper performance of their function. A history of the 
causative disease may be obtained, or the disease itself will 
be present. Impetigo, long- continued sycosis, inflammatory 
diseases such as erysipelas, parasitic diseases such as favus 
and ringworm, and destructive new growths such as syphilis 
and lupus, all may cause alopecia follicularis. 

The etiology, diagnosis, prognosis, and treatment of this 
form of baldness is the same as the disease that gives rise to 
it, for which we must refer to the proper sections. 

Alopecia Areata. Synonyms : Area celsi ; Area occi- 
dental diffluens, seu serpens, seu tyria ; Alopecia circum- 



80 



DISEASES OF THE SKIN. 



scripta ; Porrigo seu tinea decalvans ; Vitiligo capitis ; 
Ophiasis ; Phy to- alopecia ; (Fr.) Teigne pelade ; Pelade ; 
(Ger.) Die kreisfleckige Kahlheit ; Circumscribed baldness. 
This form of baldness usually begins suddenly, the patient 
discovering by accident, or being told by someone, that he 
has a bald spot. Sometimes, on waking in the morning, the 
patient is astonished to find loose hairs in his bed and, on 
looking in the glass, to see that he has a bald patch on his 

Fig. 8. 




Alopecia areata. 

head. In some cases the hair fall may have been preceded for 
days or weeks by neuralgic pains in the head. In most people 
there are no premonitory symptoms, and apart from the bald 
spots no discomfort on the part of the patient, nor cutaneous 
lesions. The neuralgia may continue after the hair fall, or 
it may cease. There may be but one bald patch or there 
may be a dozen patches. A patch may be as small as a 
three cent silver piece or as large as a silver dollar. If 
larger — and the whole head may be completely bereft of hair 
— the patch is formed by the coalescence of several smaller 
ones. A patch may attain its full size at once, or it may 
slowly enlarge, spreading at the periphery. The patches 






ALOPECIA. 81 

are more or less perfectly oval or circular in shape, and 
sharply defined against the surrounding hair. Patches 
formed by the coalescence of other patches lose the oval 
outline, and may have a scalloped border. The color is 
usually that of the normal scalp ; it may be pale or hyper- 
semic. The patch is perfectly bare and smooth, without 
scales, as a rule. Sometimes it is dotted over with short, 
broken hairs, old roots that soon fall out. Sometimes it looks 
as if it were depressed, an appearance due to falling out of 
the hair roots. Any or all the hairy regions of the body 
may be affected, the patient sometimes being entirely denuded 
of hair. Most often it is the scalp that suffers, especially 
the temporal and occipital regions. Around the border of 
a recent patch the hair is loosened so that it may be readily 
extracted. The sensibility of the skin may be diminished. 
Generally it is preserved. 

The course of the disease is chronic, with a strong ten- 
dency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 
growth of a fine down upon the bald patch. This will fall 
out and be replaced by lanugo hairs that in their turn will 
fall out to be replaced by stronger hairs, until normal hairs 
will grow at last, though these at first may be white. Some 
cases relapse year after year ; in some cases the hair never 
grows beyond the lanugo stage ; and some cases remain 
permanently bald. 

Etiology. The subjects of the disease may be in appar- 
ently perfect health, but not infrequently they are of very 
nervous temperament, exhausted by overwork or nervous 
strain, or out of health in some way. Both sexes are 
affected, the male sex rather more than the female. It 
occurs very often in children. Thus Crocker, who has a 
large experience with children, met with it in children 
under twelve years old thirty-seven times out of eighty-three 
cases. The youngest case reported was at two years of age, 
and cases have been seen as late as in the sixtieth year. It 
is rather more frequent among the poor than among the 
well-to-do. It is more frequent in some countries than in 
others. Thus Crocker's tables show that in London it forms 

4* 



82 DISEASES OF THE SKIN. 

two per cent, of all skin cases ; Bulkley's tables show but a 
little more than one-half of one per cent, in New York. 

The disputed points in the etiology of alopecia areata are 
its contagiousness, and whether it is a neurosis or a parasitic 
disease. At the present time it is impossible to decide with 
absolute certainty which of the contending parties is right. 
Most instances of contagion have been reported by French 
observers whose diagnostic skill we can hardly call in ques- 
tion. They have reported instances in which a large number 
of cases have appeared in barracks or schools and from there 
spread to neighboring towns. In England, similar apparent 
epidemics have been reported, but as a fungus indistinguish- 
able from the trichophyton fungus was found in the sur- 
rounding hairs, they were doubtless instances of bald ring- 
worm. It is possible that the French epidemics were of 
similar character. Certainly the body of experience is 
against the contagiousness of the disease. Besnier and 
Doyon, 1 who believe firmly that the disease is contagious, 
think that it is transmitted most often by means of the 
barber's utensils, and that it is impossible in a great number 
of cases to trace the contagion. 

As to the parasitic origin of the hair fall, it is as yet not 
proven. A goodly number of skilled microscopists have 
described the fungus, but they do not agree amongst them- 
selves, and so we are justified as regarding the question as 
unsettled. 

This leaves only the neurotic theory, and by the majority 
of dermatologists the disease is believed to be a tropho- 
neurosis. It has been known to follow blows or injuries to 
the head, moral or mental shock, operation on the neck, and 
experimentally by injury to or extirpation of the second 
cervical ganglion in cats. 

Pathology. Though hairs taken from the margin of an 
advancing area show atrophic changes, there is nothing dis- 
tinctive about such changes. The most exhaustive study of 
the disease of recent date is that by A. R. Robinson. 2 He 

1 Path, et Trait, des Mai. de la Peau : Kaposi. French edition, Paris, 
1891. 

2 Monatshefte f. prakt. Dermal, 1888, vii. 409. 



ALOPECIA. 83 

found evidences of inflammation, and some round-cell infil- 
tration confined principally to the perivascular region. In 
recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. In 
recent cases the hair follicles were either without hair, or 
contained a lanugo hair or a hair just about to fall. The 
hair-roots, where present, showed atrophic changes. In 
advanced cases the sebaceous glands were degenerated or 
had entirely disappeared. In the worst cases there was 
complete atrophy of the hair follicles and of the subcuta- 
neous fatty tissue. He also describes the presence of various 
cocci in the lymph spaces of the corium and the walls of a few 
of the vessels, which he regards as the cause of the disease. 

Diagnosis. A typical case of alopecia areata is so pecu- 
liar that there is little danger of mistaking it for anything 
else. It differs from trichophytosis capitis in its sudden 
onset, its perfectly bare, smooth, non-scaly surface, without 
broken, split, and gnawed-off hairs, and in the absence of 
the trichophyton fungus from the hair and scales taken from 
the neighboring parts. In bald ringworm patches, which 
resemble alopecia areata, the fungus will be found in the 
neighboring hair, or some characteristic "stumps" will be 
found on the scalp. In adults, ringworm of the scalp is 
very rare. It differs from favus in the absence of cupped 
crusts at any time in its course, in the scalp not presenting 
that cicatricial appearance always met with in favic bald- 
ness, and in complete absence of fungus growth. 

The baldness due to syphilis may resemble that of alopecia 
areata, but other symptoms of syphilis will be present, and 
there will never be a history of the formation of well-defined 
oval or circular areas. Lupous erythematosus at times affects 
the scalp, and produces circumscribed bald areas ; but these 
are not oval or round, and the skin is red and scaly, and 
evidently cicatrized. The alopecies innominees of Besnier 
is extremely difficult to diagnose from alopecia areata. It 
differs in not forming regular oval or round bald areas, but 
rather irregular ones, with clumps of hair at their borders ; 
in having a cicatricial appearance ; and in presenting, at 



84: DISEASES OF THE SKIN. 

first, at least, some evidences of dermatitis or folliculitis. 
This type of baldness has not yet become well recognized. 

Treatment. In a disease that is essentially self-limited, 
it is hard to estimate how much good our remedies do. One 
duty we have without peradventure, and that is, to look after 
the general condition of the patient. A large number of the 
cases require a stimulating and tonic treatment — iron, quinia, 
strychnia, arsenic, cod-liver oil, or hypophosphites. Chil- 
dren should be allowed to run free and taken out of school. 
Our hardest task will be to manage those nervous patients 
who are ever a trouble to us. 

As far as local treatment is concerned, it may be summed 
up in two words : patience and stimulation. As many of 
our parasiticides are stimulating to the skin, they may be 
used with benefit, whether we believe in the parasitic cause 
of the disease or not. 

The stronger water of ammonia dabbed on to the scalp 
by means of a swab, care being taken to guard the eyes, will 
be beneficial in some cases. It is remarkable how little re- 
action this powerful remedy will cause in alopecia areata. 
Pilocarpine, in hypodermic injections, or in ointment form, 
is at times beneficial. Sulphur ointment well rubbed in ; 
painting the scalp with acetic acid until it whitens, and then 
sponging off with cold water, and repeating every three or 
four days ; chrysarobin, fifteen or twenty grains to the ounce, 
well rubbed into the scalp once a day; carbolic acid (95 per 
cent.) applied every two weeks or so to small areas at a time; 
the bichloride of mercury, two to four grains to the ounce 
in alcohol, or oleum pini sylvestris ; the oleate of mercury, 
in the strength of 2 to 10 per cent. ; blistering with can- 
tharides ; or 33J per cent, of iodine in collodion, and gal- 
vanism, have one and all been followed by the return of the 
hair. 

Moty 1 reports good results from hypodermic injections of 
bichloride of mercury, injecting five or six drops of an 
aqueous solution (1 : 500) into many places about each 
patch. In a later number of the same journal (p. 864) he 

1 Ann. Derm, et Syph., 1891, ii. 406. 



ANGIOMA PIGMENTOSUM. 85 

announced that he then used a 4 per cent, solution of the 
mercury, with a 2 per cent, solution of cocaine ; that he 
made but a single- drop injection in a medium-sized patch, 
and four to five injections about a large patch and at its 
periphery. Pauses of four days were taken between the 
injections, and a cure is expected after the fourth series. 

It is advisable to pluck the loose hair from around the 
patch for a zone of perhaps an eighth or a quarter of an 
inch. Every few days slight traction is to be made on the 
hairs surrounding the patch, and all the loose ones pulled. 
Massage is also useful. 

Peognosis. Even if left to itself, the chances are that 
the hair will grow in again This good prognosis should be 
guarded when the patient is past middle life, and in those 
malignant cases in which there is complete baldness that has 
lasted several years. 

Alopecia Circumscripta. See A. areata. 

Alopecie Innominee. See Folliculitis decalvans. 

Alphos. See Psoriasis. 

Anaesthesia (A 2 n-e 2 s-the r zi 2 -a 3 ) is a loss of sensation in 
the skin which occurs in a number of diseases of the nervous 
system, notably in hysterical affections. It may be general, 
or partial, or affect but one-half of the body. There may 
be loss of sensibility to pain while the tactile sense is pre- 
served {analgesia), or intense pain with loss of ordinary 
sensibility (ancesthesia dolorosa). There are many sub- 
stances which locally applied will cause anaesthesia, such as 
carbolic acid, cocaine, aconite : and many others which will 
abolish sensation when taken internally. The subject 
belongs to the domain of the neurologist. 

Anatomical Tubercle. See Tuberculosis verrucosa cutis. 

Angeioma (A^-ji-o'ma 3 ) or Angioma. An angioma is a 
tumor or new growth made up of bloodvessels or lymphatics. 
It is usually congenital. For convenience the vascular 
angiomata will be described under Naevus, and the others 
under Lymphangioma. 

Angioma Pigmentosum et Atrophicum is the name pro- 



86 DISEASES OF THE SKIN. 

posed by R. W. Taylor for the xeroderma of Kaposi, and 
is described in this book under Atrophoderma pigmentosum, 
which see. 

Angioses. " Disorders of the cutaneous vascular appa- 
ratus which embrace the common eifects of engorgement, 
ischsemia, transudation, and inflammation." 1 

Angio-keratoma 2 is the name given by Pringle to a 
peculiar disease of the skin of the hands, feet, and ears, that 
has been called telangiectatic warts or verrues telangi- 
ectasiques. 

Symptoms. It follows chilblains, and affects the dorsal 
aspects of the hands and feet. The eruption consists in 
tiny, almost imperceptible pink points, that do not dis- 
appear on pressure ; of pin-point to pin-head darker spots 
that can be made to almost disappear on pressure, leaving 
a deep-red capillary loop in the centre ; and of clustered 
telangiectatic points forming small irregularly shaped, 
slightly elevated groups. These groups may be as large as 
a split-pea or bean ; they may project for half a line above 
the surface ; are hard, rough, warty-looking, and of dull 
purplish-brown color. Pressure upon them brings out the 
telangiectatic character of the growths. When pricked 
with a needle free hemorrhage takes place. The eruption 
is symmetrical as a rule, and usually affects more than one 
member of a family, and they are young adults. There 
are no subjective symptoms It will thus be seen that in 
many points this disease bears a close resemblance to 
atrophoderma pigmentosum. 

Treatment. The treatment that proved most beneficial 
was by electrolysis. 

Anhidrosis ( A 2 n-hi 2 d-ro'-si 2 s) or Anidrosis ( A 2 n-i 2 d-ro'si 2 s). 
By this is meant an affection of the sweat glandular ap- 
paratus attended by a diminution or more or less complete 
suspension of its functions. It is a symptom rather than 
a disease. It may be local or general ; temporary or per- 
manent ; symptomatic, as in fevers and diabetes ; congenital, 

1 Bronson : Journ. Cutan. and Gen.-urin. Dis., 1887, v. 371. 

2 Brit. Journ. Dermat., 1891, iii. 237. 



ATROPHIA CUTIS. 



87 



as in xeroderma ; or neurotic. Some people never sweat 
preceptibly. In certain skin diseases, such as psoriasis, 
scleroderma, squamous eczema, and ichthyosis the affected 
areas do not sweat. Its treatment is tonic by exercise and 
bathing. In symptomatic cases we must strive to remove 
the underlying cause. For congenital cases we can do 
nothing. 

Anonychia (A 2 n-o 2 n i 2 k'-i 2 -a 3 ) means congenital absence 
of the nail. 

Anthrax (A 2 n-thra 2 x). See Carbuncle and Pustula 
maligna. 

Area Celsi. See Alopecia areata. 

Argyria ( A 3 r-j i 2 r-i 2/ a 3 ) is the blue or black discoloration of 
the skin and mucous membranes, due to the deposition of 
particles of silver in the rete, sweat glands, and about the 
hair follicles, where it turns black by exposure to the sun- 
light. It used to be seen more often than now, w T hen silver 
salts were used in the treatment of epilepsy. It is a 
permanent staining. 

Arthritide Pseudo-exanthematique. See Pityriasis rosea. 

Asteatosis (A 2 s-te-a 3 -to r -si 2 s), an absence of sebaceous mat- 
ter. See Xeroderma. 

Atheroma (A 2 th-e 2 r-o r -ma 3 ). See Sebaceous Cyst. 

Atrophia Cutis or Atrophoderma. Atrophy of the skin 
may be quantitative or qualitative ; idiopathic or sympto- 
matic ; diffused or circumscribed. Crocker 1 gives this use- 
ful table : 

Juvenilis 



Atrophoderma 
Idiopathicoi. 



Diffusum 



Senilis 



Atrophoderma 
Symptomaticum. 



Circumscriptum 
(striae et maculae) 

Xeuriticum 

(glossy skin) 

Morborum cutis 



Pigmentosum. 

Albidum. 

Quantitativum. 

QualitatiYum. 
f Traumaticum. 
t Xon-traurnaticum. 

f Traumaticum. 
\ iSon-trauniaticum. 

Scleroderma. 

Seborrhoea. 

Lupus. 

Syphilis. 

Favus, etc. 



Diseases of the Skin, Lond. and Phila., 1888. 



88 



DISEASES OF THE SKIN. 



The symptomatic atrophies due to other diseases will be 
spoken of under their proper headings. The other forms 
of atrophy will be considered here. 

Atrophoderma Pigmentosum. Synonyms : Xeroderma 
pigmentosum (Kaposi) ; Angioma pigmentosum et atro- 



Fm. 9. 




Atrophoderma pigmentosum. (After Taylor.) 



phicum (Taylor) ; Dermatosis Kaposi (Vidal) ; Liodermia 
essentialis cum melanosi et telangiectasia (Neisser); Mel- 
anosis lenticularis progressiva (Pick) ; Lentigo maligna 
(Piifard) ; Epitheliomatose pigmentaire (Besnier). This is 
a very rare disease of the skin first described by Kaposi in 
1870 under the name of xeroderma, to which he subse- 
quently added the adjective pigmentosum. Only some 
fifty-six cases have been reported. It is a congenital dis- 
ease ; almost all cases begin before the second year of life. 



ATROPHODERMA PIGMENTOSUM. 89 

Symptoms. It affects the parts most exposed to the air: 
the face, neck, chest, and back down to the level of the 
clavicles, or even the third rib, the backs of the hands, fore- 
arms, and upper arms. The hands, face, and neck are most 
markedly diseased, while a few cases have occurred upon 
the legs and backs of the feet. It begins with erythematous 
patches like those produced by sunburn. After a time 
brown or black freckle-like spots form upon the erythem- 
atous ones. They are from pin-head to bean size, and round 
or irregularly shaped. The pigmented spot in time gives 
place to a white atrophic one, and the skin becomes too 
small for the underlying parts, so that it appears drawn, and 
in some places bound down. A fully developed case pre- 
sents a vast number of lentiginous spots, interspersed with 
white atrophic spots and stellate and striated telangiectases. 
After a time, on account of the atrophy of the skin, we 
find ectropium, thinned alse nasi, and contracted nasal and 
oral orifices. There may be white atrophic spots on the 
mucous membrane of the lips. Conjunctivitis generally 
supervenes upon the ectropium and the discharge from the 
eyes sets up ulcerations which in their turn give rise to 
other ulcerations. Warty growths at last appear, and 
these are prone to take on malignant action and be con- 
verted into epitheliomas, and the patient dies at an early 
age from marasmus. At first, however, there is no dis- 
turbance of the health. 

Etiology. The etiology of the disease is obscure. It is 
supposed by some to have its starting-point in irritation of 
the skin by the sun or other irritant. Many of the cases 
begin in the summer. It is supposed by others to be a 
tropho-neurosis. It is found in both sexes about equally, 
but is peculiar in affecting several members of the same 
family and of the same sex. It is not hereditary. In a 
few of the cases there was a history of cancer. 

Diagnosis. The disease is to be differentiated from sclero- 
derma by the peculiarity of its being limited to exposed 
parts, by lacking stony hardness, by occurring early in life, 
and by the general picture of pigmented and atrophic spots 
and telangiectases being intermingled. It differs from 



90 DISEASES OF THE SKIN. 

urticaria pigmentosa in not itching, and not occurring upon 
the trunk, and in having telangiectases and warty or 
epitheliomatous growths. 

Treatment. Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as possible, 
and the warty growths and epitheliomatous nodules de- 
stroyed at an early date so as to prevent the development 
of epitheliomatous or carcinomatous ulcers. A saturated 
solution of boric acid will do much for the eyes ; the ulcers 
may be treated with iodoform or aristol powder, or a dilute 
ammoniate of mercury ointment ; while the warty growths 
should be scraped off with the sharp spoon. 

Atrophoderma Albidum is the name used by Crocker 
for a second form of the xeroderma pigmentosum of 
Kaposi, which is described by the latter as beginning in 
childhood ; affecting most frequently the lower extremities, 
and less often the forearms and hands ; and characterized 
by thinness of the skin which in some places is stretched 
and cannot be readily taken up into folds. The color of the 
skin is pale and white with a delicate rosy shimmer in places ; 
and here and there its epidermis peels off in asbestos-like 
lamellae. The treatment is simply protective. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes are also present, as a rule. It may 
be partial or general. The skin looks wrinkled ; it is thrown 
into folds ; is dry and sometimes scaly, and is often of darker 
color than normal. By pinching up the skin the thinness 
of it is readily appreciated. With the atrophy of the skin 
there is likewise loss of the subcutaneous fat ; pruritus ; and 
verruca senilis. Treatment is out of the question. 

Atrophoderma Idiopathica Diffusa. Diffused idiopa- 
thic atrophy of the skin is a very rare affection. It may 
be congenital, or acquired; general or partial. The subcu- 
taneous tissue disappears, so that the skin lies close to the 
underlying parts. It is thin, pale, stretched, easily mova- 
ble over underlying parts, and allows the bloodvessels to 



ATROPHODERMA STRIATUM. 91 

show through. In some cases thick scaly plates form, while 
in others these are wanting, and there is only slight scaling. 
The elasticity of the skin is lost, so that if it is pinched up 
into folds these slowly flatten out. In some cases the skin 
seems too small for the body, which, on the face, gives rise 
to ectropion and other deformities. The sensibility of the 
skin may not be diminished. The patients are susceptible 
to cold. Ulcers are prone to form upon slight injuries. 
The hair is destroyed. The disease is probably a tropho- 
neurosis. One case was ascribed to exposure to cold. 1 

Hardaway 2 reported two cases occurring in a brother and 
sister ; and Ohmann-Dumesnil 3 has met with a case of 
atrophy of the skin and muscles of the right arm apparently 
following an injury to the radial nerve by means of a burn 
on the hand. 

One variety of diffused idiopathic atrophy of the skin is 
that called hemiatrophia facialis progressiva, in which 
only one-half of the face is affected, and the skin becomes 
thinned and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy skin of 
Paget, Weir Mitchell, and others. It commonly affects the 
fingers, less often the extremities, and follows upon disease 
or injury of nerves. The fingers become dry, red, or mot- 
tled, look glazed or as if varnished, and are shrunken. 
The natural lines of the skin disappear, and the nails fall 
off. If parts covered with hair are affected, the hair falls. 
The tendency is to spontaneous recovery. 

Atrophoderma Striatum et Maculatum. By this is 
meant circumscribed atrophic streaks or spots. They may 
be idiopathic or symptomatic. The idiopathic form is far 
more rare than the symptomatic form. 

Symptoms. The idiopathic streaks are met with most 
often about the thighs, buttocks, and lower anterior part of 
the abdomen. They are one or two lines wide, slightly 
curved, and from one to several inches long. There are 
usually several present, and then they are arranged parallel 

1 Pospelow : Ann. Derm, et Syph., 1886, vii. 505. 

2 Trans. Amer. Derm. Association, 1884. 

3 Alienist and Neurologist, July, 1890. 



92 DISEASES OF THE SKIN. 

to one another and run in an oblique direction. The 
macules are isolated, from pin-head to finger-nail size or 
larger, occur most frequently on the lower part of the 
trunk, but may occur as high up as the neck, and are less 
common than the streaks. Both forms of lesion are de- 
pressed below the surface of the skin, and of a pearly or 
bluish- white color, and have a glistening, scar-like appear- 
ance. They are not primary atrophies, but succeed to an 
erythematous hypertrophic lesion, in this greatly resem- 
bling morphcea. They give rise to no inconvenience, and 
are accidentally discovered. They usually are permanent, 
though they may become less pronounced in time. 

Etiology. Their etiology is obscure. By many they are 
regarded as tropho-neuroses. Shepherd 1 has recently re- 
ported cases of atrophic spots and lines following fevers. 

Symptomatic lines and macules are very common, and 
are caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissue of the skin. 
If the fibres are ruptured the striae will be most pronounced, 
and there will be little left of the skin but the epidermis 
and a thin fibrous membrane. 2 This form of atrophy of the 
skin is seen upon the abdomen of pregnant women (linece 
albicantes), and on the breasts of nursing women. In fact, 
anything that greatly distends the skin may give rise to 
them, such as abdominal ascites, ovarian or other tumors. 

Treatment. The treatment of these cases is purely 
expectant. Both the idiopathic and symptomatic atrophies 
may grow less pronounced in time. 

Atrophia Pilorum Propria. Atrophy of the hair exists 
under two forms, namely, Fragilitas crinium, and Trichor- 
rhexis nodosa. In both forms the hair-shaft is easily fria- 
ble and splits or breaks of itself, or by the slightest traction. 

Fragilitas Crinium. This disease has been called scis- 
sura piloru??i, and has for its distinguishing features split- 
ting of the hair. The cleft is usually at the free extremity, 
and at times runs some distance up the shaft. The split 

1 Trans. Amer. Derm. Association, 1890, p. 23. 

2 Taylor, E. W. : N. Y. Med. Journ., 1886, xliii. p. 1. 



ATROPHIA PILORUM PROPRIA. 93 

hairs are either scattered here and there through the other- 
wise normal hair, or all the hairs of the part are split. 
The disease occurs most often upon the scalp, the beard 
being the place next most frequently affected. It is a com- 
mon occurrence in the long hair of women. The shaft may 
be split into two or more fibrillse, and these spread out from 
each other simply, or curve up upon themselves. The 
cleft may also occur in the middle of the shaft, or at its 
exit from the follicle, and in the latter case the shaft will be 
split throughout its entire length, the segments either sepa- 
rating or holding together. Duhring 1 has reported a case 
occurring in the beard in which the hair began to split 
within the bulb. Besides the splitting, the hair may show 
no other abnormality, but it is generally more dry and 
brittle than normal, and may be irregular and uneven in its 
contour. The bulb of the hair may be normal or atrophied. 

Etiology. The cause of the idiopathic fragilitas crinium 
is yet undetermined. The disease is, without doubt, due to 
some interference with the nutrition of the hair, probably 
a yet undetermined tropho-neurosis. 

Treatment. When occurring only at the free end of 
long hairs, they should be cut above the cleft. In all cases 
the scalp should be kept in good condition, as directed under 
Alopecia prematura. If the disease occur in the beard, 
shaving would at least remove the deformity, and possibly 
cure the disease. 

Trichorrhexis Nodosa. Synonyms : Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

Symptoms. The disease generally affects exclusively the 
hair of the beard and moustache, and here it reaches its 
highest development. Very infrequently it is found in the 
hairs of the pubic region, and still more rarely in the head- 
hair. Raymond 2 says that he has found it on the labia 
majora in 40 per cent, of all women he has examined, and 
specially in fat women with intertrigo. He has found it 
also on scrotal hairs. It consists of one or more whitish or 

1 Amer. Journ. Med. Sci., July, 1878, p. 88. 

2 Ann. Demi, et Syph., 1891, ii. p. 568. 



94 DISEASES OF THE SKIN. 

grayish shiny transparent nodular swellings occurring along 
the shaft of the hair. In people with red hair the color may 
be black. The number of nodes that may be present is 
from one to five ; and their size will vary with the diameter 
of the hair. The nodes, according to S. Kohn, 1 occur 
usually in the upper third of the hair. These nodes give 
to the hair an appearance not unlike that produced by the 
presence of the nits of pediculi. The hair is exceedingly 
brittle and fractures upon slight traction, or spontaneously, 
the fracture taking place through a node, and the hair fibres 
separating like the hairs of a brush. When many hairs in 
the beard are thus broken, their frayed-out ends make the 
beard look as if it were singed. Sometimes the hair fibres 
splinter about the node, but the two ends do not separate, 
and this gives an appearance like as if two small paint- 
brushes were pushed together. Sometimes the hair pre- 
sents an irregular contour, and looks as if frayed along its 
entire length. While the fracture is usually transverse, if 
there should be an excessive amount of medulla present in 
the node, it may be longitudinal. The hairs themselves are 
usually firmly fixed in the follicles. 

Etiology. The cause of the disease is obscure. It is 
probably a tropho-neurosis interfering in some way with the 
proper nutrition of the hair. It does not seem to depend 
upon any diathesis, nervous or otherwise. Anderson 2 has 
reported a case of hereditary trichorrhexis nodosa, the 
disease in his patient being congenital or nearly so. 

The cause of the splitting of the hair is ascribed by some 
investigators to a degeneration of the medulla, a conse- 
quent rapid accumulation of cells at one point which event- 
ually bursts open the hair sheath. Pye-Smith 3 regards it as 
due to a gradual drying of the cortical substance, and a 
consequent loss of coherence of its constituent fibre-cells, 
followed by the breaking up into a granular material and 
swelling of the cells of the medulla, till the rupture of the 

1 Vierteljahr. f. Derm. u. Syph., 1881, viii. 581. 

2 Lancet, 1883, ii. 140. 

3 Trans. Path. Soc., Lond., 1879, xxx. 439. 



ATKOPHIA PILOKUM PROPRIA. 95 

cortex is complete, there being nothing left to hold the hair 
together. 

By some it is regarded as purely mechanical, due to the 
habit of the patient of handling the beard. 

The microscopical examination of the affected hair shows 
that in the early stage of development of the disease there is 
is simply a spindle-formed thickening in the continuity of the 
shaft of the hair, and a swelling of the medulla, while the 
cuticle is still intact. Later the cuticle becomes cleft, and 
the cleavage extends on all sides of the node till the brush- 
like appearance is produced by spreading of the separate 
fibres. At the same time with the cleaving of the cuticle, the 
medulla undergoes degenerative changes, and either slowly 
disappears or else, according to Pye-Smith, oozes out between 
the separated fibres as a finely granular material. There 
is either no marked change in the appearance of the hair- 
root, or it is slightly atrophied. Air-globules are only very 
occasionally found in or about the nodes. 

Treatment. The treatment of the disease is very unsatis- 
factory. Continued shaving probably offers the best hopes of 
any plan. All sorts of applications have been made to the 
affected parts, generally of a stimulating character, particu- 
larly various forms of mercurials, but without curative 
effect. Gamberini, in his work on the hair, recommends 
either bathing the part with a lotion composed as follows : 

R. Potass, subcarb., ^iijj 8 1 

Alcohol, dil., gv; 100 M. 

or inunctions of tannic acid or oil of cade. 
Schwimmer advises that an ointment of 



K 



Zinci oxid., 


gr. vij ; 


115 


Sulphur, loti, 


gr. xv ; 


3 


Ung. simp., 


^iiss ; 


30 



M. 



be rubbed in morning and evening. 

Besnier finds it useful to pluck the diseased hairs and to 
apply to the newly formed hairs tincture of cantharides, pure 
or diluted. 



96 DISEASES OF THE SKIN. 

Atrophia Unguium. Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as lichen 
ruber acuminatus, pityriasis rubra, psoriasis, and syphilis ; 
or it may be caused by the invasion of the nail bed by para- 
sites, as in favus and ringworm. It may also occur like 
defluvium capillorutn as a sequence to some grave acute 
illness such as typhus fever or scarlatina, or some cachexia, 
such as diabetes. The nails may be congenitally absent or 
deficient, or become so without apparent cause. Injuries, 
and certain chemicals, will cause the nails' to atrophy and 
fall. Atrophy is shown by white spots in the nails, by 
transverse white lines, by longitudinal or transverse furrows, 
by a worm-eaten appearance, or by a general thinning and 
breaking away of the nail plate. 

Treatment. The treatment is most unsatisfactory. If 
the cause can be discovered and removed, the nails will 
recover. In many cases all we can do is to protect the nail 
by rubber cots, or by the use of wax or other protective. 
Ointments of lead, zinc, or mercury, may be rubbed in. 
The persistent use of sulphur ointment, combined with the 
administration of nerve tonics, will prove beneficial in those 
cases apparently dependent upon nerve disturbance. 

Aussatz. See Leprosy. 

Autographism. See Urticaria factitia. 

Arzneiexantheme. See Dermatitis medicamentosa. 

Baker's Itch. See Eczema. 

Baldness. See Alopecia. 

Barbadoes Leg. See Elephantiasis. 

Barber's Itch. See Trichophytosis barbae. 

Bartfinne or Bartflechte. See Sycosis. 

Biskra Bouton or Biskrabeule. See Aleppo boil. 

Blasenausschlag. See Pemphigus. 

Blutfleckenkrankheit. See Purpura. 

Blutgeschwiir or Blutschwar. See Furunculus. 

Blutschweiss. See Haematidrosis. 

Boil. See Furunculus. 



BROMIDROSIS. 97 

Bouton. See Acne. 
Bouton d'Amboine. See Yaws. 
Brandrose is a phlegmonous erysipelas. 
Brandschwar. See Carbuncle. 
Bricklayer's Itch. See Eczema. 

Bromidrosis (Brom-i 2 d-ro r si 2 s). Synonym : Osmidrosis. 
This word means stinking sweat, which, though not elegant, 
is expressive. It most often affects the feet, and then is 
associated with hyperidrosis. It may be general, as in the 
negro race. The odor is not necessarily repulsive, a few 
cases having been reported in which it was that of violets. 
The axillae are, next to the feet, the most common site of the 
trouble. The odors of different fevers and cachexiae are 
usually classed under this heading, though they do not 
properly belong here. 

Strictly speaking bromidrosis should include those rare 
cases alone in'which the sweat, when secreted, has a dis- 
tinctive odor. Usually the odor in bromidrosis is not in 
the sweat, but in the products of decomposition, the fatty 
acids, and the like. When the feet are the parts affected 
they will be found to be of a pinkish color about the soles 
and between the toes, or the skin will look sodden and 
grayish. When the hyperidrosis is well marked, and it 
commonly is, the feet may be so tender as to interfere with 
locomotion. The stench from a pronounced case is such 
that it is almost impossible to stay near the subject of the 
disease. 

Etiology. The cause of general bromidrosis is either 
inherent in the race, or unknown. Most of the cases, apart 
from the racial ones, have been in hysterics. In the usual 
form of the disease it is due to decomposition of the sweat 
in the stockings, shoes, or clothing of the individual. 
When the part is uncovered and kept clean there is no odor. 
Thin has described a parasite, that he has named bacterium 
foetidum, as the cause of the disease. It has been supposed 
that this bacterium can live only in an alkaline medium. 
The sweat is acid, and therefore on most feet it does no 
harm ; but when hyperidrosis macerates the epidermis and 

5 



98 DISEASES OF THE SKIN. 

allows of the escape of serum, the acidity of the sweat is 
neutralized, and the bacterium flourishes. 

Treatment. The treatment of the general cases is of no 
effect. Of the local cases the hyperidrosis is to be overcome, 
as will be described in its proper place. The special treat- 
ment directed to the cure of the odor is to wash the feet with 
soap and water two or three times a day, to put on a clean 
pair of stockings every morning, to ventilate the shoes 
thoroughly, and to dust the feet, between the toes, the 
stockings, and the inside of the shoes with boric acid. Thin 
recommends the wearing of cork inside soles, which are to 
be soaked in a saturated solution of boric acid and dried, 
before using. Another useful powder is : 



R . Ac. salicylici, gjss-iij ; 5-10 

Pulv. alum exsic. vel \ z . . . -. nA 

Pulv. lycopodii, j 5nj; iUU 



M. 



to be applied in the same way, twice a day. This will cause 
the skin to exfoliate, when the treatment may be stopped. 

Bucnemia Tropica. See Elephantiasis. 

Cacotrophia Folliculorum. See Keratosis pilaris. 

Calculi, Cutaneous. See Milium. 

Callositas (Ka 2 l-loV-i 2 t-a 2 s). Synonyms: Callosity; Cal- 
lus; Tylosis; Tyloma; (Fr.) Durillon. This is familiar to 
all as the callus skin of the hands met with in oarsmen, 
blacksmiths, and in those who follow other manual occupa- 
tions, and is a hypertrophy of the epidermis consequent 
upon intermittent pressure of the skin against the under- 
lying bone. Constant pressure will cause atrophy. The 
same thickenings of the skin are found upon the soles also, 
due to going barefoot or wearing improperly fitting shoes. 
In fact they may develop anywhere under proper conditions. 

Besides this acquired form, cases of congenital tyloma 
have been met with. Unna 1 has reported five cases of this 
rare disease in one family, and has proposed for it the name 
of keratoma palmare et plantare her edit arium. Other cases 
have been described under the name of ichthyosis palmar is et 

1 Vierteljahr. f. Derm. u. Syph., 1882, x. p. 231. 



CANCROIDE. 99 

plantaris. Besnier and Doyon place this under the congenital 
and hereditary form of Jceratodermie symetrique des extrem- 
ites. They describe a second form that develops in second 
childhood in which the callosities are surrounded by an 
erythematous zone, and interfere with walking and grasping. 
Their development is probably due to some central neurosis, 
A third variety, also due to a tropho-neurosis, exhibits 
numerous islands of callosities of the hands and feet out 
of all proportion to the pressure. At times callosities will 
develop without any apparent cause, and may involve either 
the feet or hands or both. In all forms Ave have a hyper- 
trophy of the corneous layer of the skin, and the formation 
of more or less smooth and thickened plates of skin which 
are of more or less gray color. 

Treatment. No treatment is necessary for the acquired 
forms. Cessation from using the hands will be followed in 
course of time by the disappearance of the callus. To 
hasten their removal, or to cause it in the congenital or 
spontaneous forms, we may use maceration with rubber cloth 
continuously applied to the part, or a plaster of salicylic 
acid, or a solution of salicylic acid ten to twenty per cent, in 
ether or collodion. The action of these remedies will be 
aided by previously paring down the part with a sharp knife. 

Rosen 1 recommends dampening the part with a saturated 
solution of boric acid, and covering it with a thick layer of 
salicylic acid in crystals, over which is placed a four-folded 
layer of borated lint, and then a thick piece of gutta-percha, 
the whole being confined by a bandage. After five days 
this is to be removed, when the growth may be raised easily 
from its bed, and there will be soft skin underneath. 

Callus. See Callositas. 

Calvez ^ 

Calvezza > • See Alopecia. 

CalvitiesJ (Ka 2 l-vi 2 s'h'i 2 -ez). 

Cancer. See Carcinoma and Epithelioma. 

Cancroide. See Epithelioma. 

1 Miinchen. med. Woch., Feb. 28, 1888. 



100 DISEASES OF THE SKIN. 

Canities (Ka 2 n-i 2/ shi 2 -ez). Synonyms: Trichonosis cana; 
Trichonosis discolor; Poliothrix ; Poliosis; Trichonosis 
poliosis ; Trichosis poliosis ; Spilosis poliosis ; Poliotes ; 
Grayness of the hair ; Whiteness of the hair ; Blanching of 
the hair ; Atrophy of the hair pigment. 

Grayness or whiteness of the hair may be congenital or 
acquired ; the latter is by far the most common. The 
whiteness is either partial or complete. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously amongst the normal-colored 
mass. When the whiteness is general, we have albinism 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age, it may be con- 
sidered as premature ; and when after this age, as senile. 
Premature canities is by no means uncommon, many per- 
sons becoming gray between the twentieth and twenty-fifth 
year. The hair which, as a rule, first whitens is that of 
the temples ; then follows, with more or less rapidity, that 
of the vertex and whole head. Sometimes the beard first 
turns gray, but usually it changes color after the hair of 
the scalp. The last hair to become gray is that of the 
axillae and pubis. When the graying is due to some pass- 
ing cause, as anxiety or some diseased state, the process 
may cease completely upon removal of the cause. Usually 
the whiteness is "permanent. As a rule, there is no change 
in the color of the scalp, though in some cases gray tufts 
are found upon pale-yellow patches of scalp. As in alopecia, 
so in canities, men are more frequently affected than 
women. 

The hair in canities is usually unchanged except in color, 
but it may be drier and stiffer than normal. Canities may 
exist for years without alopecia. According to Landois, 
incipient baldness usually follows senile canities in from 
one to five years. 

The hair turns gray first at its root. The color at first 



CANITIES. 101 

is gray on account of the mixture of the normal color with 
the whiteness due to the absence of pigment. Gradually, 
the white parts gain the ascendant, and the whole hair is 
blanched, becoming finally of a yellowish or snowy white- 
ness. The darker the hair is originally the more it is prone 
to turn gray. 

Sudden change of color of the hair from its normal 
hue to perfect white has been too well authenticated to allow 
of a doubt as to its occurrence, though it has been denied 
by good authorities, who have questioned the correctness of 
the observations reported, 

Ringed hair is an anomalous variety of blanching of the 
hair in which the affected hairs are marked by alternate 
rings, one being that of the normal color, and the next 
white. The occurrence of this disease is very rare, and but 
few cases have been reported. 

The hair has been known to lose its color under varying 
circumstances. Thus Wallenberg 1 reports a case in which, 
after an attack of scarlatina, the patient's brown hair was 
entirely lost and replaced by a growth of white hair. Pro- 
longed residence in a cold climate, with much exposure, 
will cause the hair to turn gray. Sometimes the hair will 
change its color with the season, becoming gray in winter 
and darker in summer. On the other hand, Cottle 2 gives 
prolonged residence in hot climates, with much exposure, as 
a cause of canities. Albinoes, we know, are most frequent 
in the negro races, which inhabit the hot countries. 

Etiology and Pathology. Senile canities and many 
cases of the premature form are due to an obscure change 
in the nutrition of the hair papillae which interferes with 
the production of pigment. Whatever the nature of the 
change may be, only this function of the papillae seems to 
be interfered with, as the hair-forming function is in full 
activity, judging from the fact that the hair in many cases is 
in full vigor. In cases of sudden blanching of the hair, the 
change of color is dependent upon the formation of air 

1 Arch. f. Derm, und Syph., 1876, Heft 1. 

2 The Hair in Health and Disease. London, 1877. 



102 DISEASES OF THE SKIN. 

bubbles between the hair cells of the cortical substance, the 
presence of the air rendering the cortical substance opaque, 
so that the color of the pigment is obscured. If one of 
these hairs is placed in hot water, ether, or turpentine, the 
air bubbles will be driven out, and the hair will reassume 
its normal color. There are various agents which act as 
active or exciting causes of canities. Age is one of the 
most prominent of these. Heredity exerts marked influence 
upon the blanching of the hair, most of the members of 
certain families turning gray at an early period of life. 
Neuralgia of the fifth nerve, dyspepsia of various forms, 
sudden fear or nervous shock (producing sudden blanching 
of the hair), abundant and frequent hemorrhage, excesses 
of all kinds, chronic debilitating diseases (as syphilis, 
malaria, and phthisis), local diseases or injuries to the 
scalp, as wounds, favus, repeated epilation, prolonged shav- 
ing, and the like, have been given by various writers as 
causes of canities. Schwimmer regards it as being prin- 
cipally a tropho-neurosis, and finds in the occurrence of 
grayness in the course of neuralgia a strong argument for 
his theory. 

Treatment. We cannot restore the color to gray hairs. 
In some cases of canities occurring in the course of neural- 
gias, if we can cure the neuralgia, the color will gradually 
return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promoter of pigmentation, as they have seen numerous cases 
of its use in Alopecia areata being followed by the growth 
of hyperpigmented hair. 

All that can be done for canities is to artifically restore 
the color by means of hair dyes ; and their use is to be 
deprecated. Happily the custom of dyeing the hair is falling 
out of fashion. 

Carbuncle (Ka 3 rb'-u 3 n-kl). Synonyms : Anthrax ;* Car- 
bunculus; (Grer.) Brandschwar. 

1 Anthrax, a term that is often applied to carbuncle, should be used 
rather for malignant pustule, or the local manifestation of splenic 
fever. 



CARBUNCLE. 103 

A phlegmonous inflammation of the skin and subcuta- 
neous tissue, attended with sloughing. 

Symptoms. The disease begins as an innocent-looking 
papule which, however, is far more painful, both subjec- 
tively and objectively, than an ordinary papule would be. 
Within twenty- four hours it becomes larger, more painful, 
slightly raised, and reddened, and is generally accompanied 
by a good deal of constitutional disturbance, such as chills, 
fever, and nervous irritation. All the symptoms increase 
in severity, the inflammation extends laterally and vertically, 
the swelling becomes darker in color, the pain more intense 
and lancinating, and the constitutional disturbance may be 
so severe that the patient is compelled to go to bed. Within 
ten days or perhaps longer, the swelling has reached its 
height. It may be two or three inches wide, with a brawny 
base that is more or less sharply defined, of irregular shape, 
and firm to the touch. Now it begins to soften, not like a 
boil with a central point, but by the formation of a number 
of pea-sized purulent points, through which sanious pus 
exudes, giving to the surface a cribriform appearance. 
Sloughing takes place through the openings, that gradually 
enlarge, so that at last there results an irregular, deep, ex- 
cavated ulcer with firm, sharply cut, everted edges. This 
gradually fills up, heals, and leaves a scar. With the dis- 
charge of the slough the patient gradually recovers his 
health, but in some cases, especially in already debilitated 
or in elderly people, the disease runs a fatal course and 
they die of exhaustion or pyaemia, or the disease runs into 
a typhoid condition preceding death. In some cases the 
resulting ulceration is very large, with a corresponding 
amount of general disturbance of the system. Dry gangrene 
may take place. 

The disease is rare in children and most common in mid- 
dle and old age. Men suffer more often than women. The 
location of the disease is most often the upper dorsal region, 
back, buttocks, and forearms, though it may occur any- 
where. It is usually single. The duration of the whole 
process is four to six weeks. 

Etiology. The causes of the disease are verv much the 



104 DISEASES OF THE SKIN. 

same as those of boils. While carbuncle is most apt to 
occur in those who are not in good health, it does occur at 
times in apparently robust subjects. Diabetics are frequent 
subjects; gout and uraemia have been considered as predis- 
posing causes. The frequent location of the disease about 
the shoulders and on the back of the neck suggests pressure 
as a determining cause. Of course, the claim of microorgan- 
isms as the exciting cause of the disease finds many ardent 
advocates. 

Pathology. To Warren, 1 of Boston, we owe one of the 
most thorough studies of the pathology of carbuncle. He 
declares it to be a spreading phlegmonous inflammation of 
the subcutaneous cellular tissue. The inflammatory cells 
cluster in and about the columnse adiposse, and push out 
latterly from them, infiltrating the skin. They reach the 
surface by mounting up along the hair follicles and erector 
pili muscles. 

Diagnosis. Carbuncle differs from furuncle in being 
single ; in its brawny base ; in its greater painfulness and 
constitutional disturbance ; in its flatter shape and larger size ; 
and especially in its opening at many points and presenting 
a cribriform surface rather than a central core and a crater- 
shaped opening. Its circumscribed shape, its lancinating 
pain, and its multiple sieve-like openings distinguish it from 
diffuse phlegmonous inflammation of the skin. 

Teeatment. As the disease is an exhausting one, the 
patient's strength is to be supported from the start, and his 
nutrition kept up by a generous diet. Fresh air by good 
ventilation must be secured. If the pain is excessive, opium 
or morphine is indicated, especially to procure sleep. Iron 
is a valuable remedy all the way through, and quinine or 
antipyrin if the fever is marked. Alcohol should be given 
if suppuration is free, especially if there are any signs of 
exhaustion. 

The local treatment has come of late years to be by the 
use of carbolic acid, and this gives such good results as to 
leave' little to be desired. The crucial incision formerly 

1 Boston Med. and Surg. Journ., 1881, civ. 5. 



CARCINOMA. 105 

practised is now considered by most modern authorities as 
harmful, though it certainly gives relief for the time by 
removing tension. In like manner the old-time method of 
poulticing is condemned, though it too contributes to the 
comfort of the sufferer. For ordinary carbuncles the most 
efficient treatment is to inject them with a five or ten per 
cent, solution of carbolic acid in olive oil or glycerin, by 
means of an ordinary hypodermatic syringe. When there 
are already sloughing points it is well to push into each of 
them a little cotton, wound on the end of a wooden tooth- 
pick and dipped in carbolic acid either pure or in one to 
four solution. The procedures are painful for a moment. 
The mass must then be covered with lint soaked in a weak 
solution of carbolic acid. It is possible to abort some cases 
by touching them with pure carbolic acid. Eade, 1 to whom 
we owe this plan of treatment with carbolic acid, says that it 
is possible to abort cases in the papular stage by continuous 
soaking with a solution of a mild antiseptic, such as boric 
or salicylic acid. 

Canquoin's paste, and a solution of chloride of zinc, 1 to 
50, have been recommended for use in the same way as the 
carbolic acid. 

Extensive carbuncles are to be treated on surgical princi- 
ples, by excision or erosion with the curette. The resulting 
raw surface, as well as that of ordinary carbuncles, is to be 
dressed antiseptically with iodoform, iodol, or aristol in 
powder. 

Carcinoma (Ka^-sr^n-o'ma 3 ). Epithelioma is the form of 
cancer that most frequently is met with in the skin. It will 
be described under its proper heading. Carcinoma of the 
scirrhus variety rarely attacks the skin, but when it does it 
may be primary or secondary. Most commonly it is 
secondary to the same disease of the breast or internal 
organs. It may follow extirpation of the primary deposit, 
and then is prone to begin in the scar. Two varieties are 
described, namely : Carcinoma lenticulare, and Carcinoma 
tuberosum. 

1 Lancet, May 19, 1888. 
5* 



106 DISEASES OF THE SKIN. 

Carcinoma Lenticulare generally appears on the chest in 
the neighborhood of the breast. It appears in the form of 
smooth, firm, glistening, dull, or brownish-red or pinkish 
nodules raised above the surface and discrete at first. In 
size the nodules vary from that of a pea to that of a bean. 
After a time the nodules run together and form a thick, 
indurated mass, which may involve so much of the chest as 
to interfere with breathing. This is the cancer en cuirasse 
of Velpeau. Now the neighboring lymphatic glands are 
involved, and the arm of the same side becomes swollen and 
useless. In a short time the nodules and the mass break 
down and ulcerate, and the patient soon dies of exhaustion. 

Carcinoma Tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the skin 
and subcutaneous tissues. These are of a dull-red, viola- 
ceous, or brownish-red color. They do not tend to run 
together, but they break down and ulcerate, and the patient 
dies just as in the lenticular variety. It usually appears in 
old people. 

In both forms there may or may not be lancinating pains, 
or there may be simply itching. In both, metastasis may 
take plnce. 

Carcinoma Melanodes is described by most authors as a 
third form of carcinoma, but Robinson, Crocker, and Brocq 
regard it as melanotic sarcoma, which see. 

Diagnosis. The diagnosis of carcinoma is not difficult 
when one is aware that there is such a disease, and knows 
that in a given case there has been, or is, a carcinoma else- 
where. The mode of evolution of the lesions, the involve- 
ment of the lymphatic glands, and the lancinating pains all 
point toward carcinoma as against a tubercular syphilide, 
lupus, or leprosy. 

Treatment. The treatment of this form of carcinoma 
is the same as of other forms, and quite as unsatisfactory. 

Causalgia (KaVaTjP-a 3 ). Neuralgia with a sense of 
severe burning pain. 



CHLOASMA. 107 

Chair du poule. See Cutis anserina. 

Chancre. See Syphilis, initial lesion of. 

Chap. Usually a mild form of eczema attended with 
superficial cracking. It is generally due to exposure to 
cold, and affects exposed parts, as the backs of the hands 
and the lips. Thorough drying of the hands after washing 
and keeping them covered from the air will prevent its 
occurrence on the hands. Avoiding wetting the lips, and 
making some greasy protecting application, will prevent the 
lips from being affected. 

Charbon. See Carbuncle. 

Cheiro-pompholyx. See Pompholyx. 

Chelis and Cheloide. See Keloid. 

Chilblain. See Dermatitis congelationis. 

Chloasma (Klo-aVina a ). Synonyms : (Fr.) Chloasme, 
Panne hepatique, Taches hepatiques, Chaleur du foie, 
Masque; (Ger.) Pigmentflecken, Leberfleck ; (Ital.) Mac- 
chie epatiche ; (Eng.) Liver spot, Moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 
formation of yellowish, browish, or blackish patches of 
various sizes and shapes. 

Symptoms. In this disease the only alteration of the 
skin is its color. The disease consists in a deposit of pig- 
ment in the rete mucosum, and occurs in the form of cir- 
cumscribed or diffused patches of yellowish to black discolor- 
ation. When the color is black it is called melasma or 
melanoderma. The size of the patches varies greatly from 
a small spot up to a general bronzing of the skin. 

The disease may be primary or secondary, idiopathic or 
symptomatic. The idiopathic forms are most often sec- 
ondary to some irritation. Thus it occurs with or in con- 
sequence of irritants applied to the skin, whether blisters or 
even sinapisms ; prolonged scratching on account of some 
pruriginous disease, such as prurigo, pruritus cutaneous, 
chronic urticaria, scabies, or pediculosis ; exposure to the 
sun's rays or high winds, or even to heat, as of the furnace 
in iron-w T orkers, and then on exposed parts. These all cause 
more or less hyperseniia of the skin, and besides the deposit 



108 DISEASES OF THE SKIN. 

of the pigment there is more or less discoloration from the 
changes taking place in the extravasated blood. Allied to 
these causes and acting in the same way is the discoloration 
of the skin of the legs met with about old varicose ulcers, 
and sometimes without the ulcers when there are marked 
varicosities. 

The symptomatic form may likewise be primary or 
secondary. It is primary in that most common form 
of all that is known as Chloasma uterinum, or the mask, 
a form of hyper-pigmentation of the skin of the face 
that occurs during pregnancy, or with uterine irritation, 
and that is not met with after the menopause. It usually 
takes the shape of a diffused brownish, light or dark dis- 
coloration of the forehead alone, or also about the mouth 
and cheeks. Usually it only extends across the forehead 
and down the temples, and is either a continuous or inter- 
rupted patch with sharply defined borders. Under the 
same conditions, there takes place a deepening of the color 
about the nipples and along the linea alba. The darkening 
of the color under the eyes of menstruating women is largely 
due to vascular congestion, and little if at all to chloasma. 
After a time in some women true chloasma does occur there. 

Primary pigmentation also occurs in certain cachexia, 
such as Addison's disease, tubercular leprosy in Europeans, 
abdominal tuberculosis, cirrhosis of the liver, cancer of the 
stomach, malaria, and multiple melanotic sarcoma. There 
is also an earthy look to the skin in secondary syphilis, as 
well as in congenital syphilis. Primary chloasma is also 
seen as the result of the ingestion of arsenic. Argyria is 
not a chloasma strictly speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphiloderma, and of lichen ruber planus ; these derma- 
toses disappearing to leave behind them for a greater or less 
length of time hyper-pigmented spots. This may occur after 
other diseases of the skin, but is usually more fugitive. It 
is also seen in senile atrophy of the skin. There is hyper- 
pigmentation about the patches of leucoderma and in sclero- 
derma. There is also a pigmentary syphilide met with 
upon the neck in women. 



CHLOASMA. 109 

Etiology. The cause of chloasma is undetermined in 
most cases. A late theory of the pigmentation following 
exposure to the sun is that it is due to the action of the 
chemical rays of the sun upon the constituents of the blood. 
We know also that in some cases of hyper-pigmentation the 
color is due to changes taking place in the coloring matter 
of the extravasated blood. That there is a relation between 
chloasma uterinum and the uterus, we know, because the 
chloasma usually clears away either after parturition, the cure 
of the uterine disorder, or the attainment of the menopause. 

Diagnosis. The diagnosis is usually easy. Discolora- 
tions caused by artificial means can be washed off. Chromo- 
phytosis is scaly and can be scraped off with the nail. 
Chromidrosis is very rare and can be washed off with 
chloroform or ether. 

Treatment. The treatment of chloasma is very unsatis- 
factory. While it is possible to remove the color, it is very 
prone to return. Acetic acid touched on in spots will 
reduce the color and sometimes remove it. The same may 
be said of other acids, care being used not to cause too 
great destruction of the skin by the stronger ones. The 
bichloride of mercury in 1 to 2 per cent, solution may be 
used for the purpose, applied repeatedly or else kept on 
continuously for three or four hours. Hardaway warns 
against its use. Salicylic acid, 10 to 15 per cent., in oint- 
ment, paste, or plaster, or in saturated solution in alcohol, 
may do well. Unna has recommended washing the part 
with alcohol, and applying a mercurial plaster made with 
the ammoniate of mercury over night. The next day this 
is to be removed and the following ointment applied : 



R . Bismuthi subnit., 1 - - _ . « 

Kaolini, 7 ^ 3JSS; 

Vaselini, ^vj ad ^jss; 30 



M. 



Brocq advises a mercurial plaster during the night, bath- 
ing morning and evening with a 3 to 5 per cent, solution of 
bichloride of mercury, and wearing during the day oxide of 
zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary dis- 



110 DISEASES OF THE SKIN". 

appearance of the pigmentation. In all cases where there 
is an underlying cause attention must be given first to it. 

Chorioblastosis is any anomaly of growth of the corium 
and subcutaneous connective tissue. (Auspitz.) 
Chorionitis. See Scleroderma. 

Chromidrosis (Krom-i 2 d-ros r i 2 s). Synonyms : Ephidrosis 
tincta; Stearrhoea or Seborrhoea nigricans; Pityriasis ni- 
gricans ; (Fr.) Cyanopathie cutanee, Melastearrhee. 

This is a condition of the body in which the sweat has an 
abnormal color. Usually it affects only limited regions, 
especially the lower eyelids. The color is most commonly 
blue or blue-black. The subjects are most often hysterical 
women, and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be affected. 
Next in frequency it is on some other part of the face where 
the colored sweat forms, but it may occur on any portion of 
the body. Besides the blue or black color, cases of yellow, 
green, brown, or even rosy color have been reported. A 
few men have exhibited the phenomenon. Hoffmann 1 re- 
ports a case of blue sweat of the scrotum of a man seventy- 
two years old ; and White 2 has met with a case of yellow 
sweat in a man twenty years old. R. W. Taylor saw one 
case of apparently blue sweat that occurred in a man taking 
iodide of potassium, and was due to a reaction between the 
starch of his shirt and the iodine contained in the sweat. 
Constipation and nervous derangements are often found in 
the cases, and the chromidrosis has been noted to grow T worse 
with increased constipation, and become better when that 
condition is removed ; to be more pronounced at menstrual 
periods, and to break out suddenly under emotional excite- 
ment. The skin may present no appearance of change ex- 
cept the discoloration, or it may have an evident deposit 
upon it. In either case the color can be removed by wiping 
with a little oil, or scraped off partially with the finger-nail. 

Etiology. The cause of the disease is obscure. It has 
been thought to be due to the presence of colorless indican 

1 Wien. med. Wochenschr., 1873, xxiii. 291. 

2 Journ. Cutan. and Ven. Dis., 1884, ii. 293. 



CHROMOPHYTOSIS. Ill 

in the sweat, which becomes blue by oxidation. This 
accounts for a few cases at least. 

Diagnosis. The diagnosis is easy, because the discolora- 
tion can be readily removed by an oiled cloth, while that of 
chromophytosis does not so readily come off, and that of 
chloasma does not yield at all. Moreover, neither of these 
two last conditions exhibits a blue color. 

Treatment. The disease requires stimulation in its 
treatment, and good results have been reported from the 
use of the following : 1 



. Ac. borici, 


gr. x; 




Ac. salicylici, 


gr. xv ; 


1 


Ungt. aquse rosse, 


3j; 


30 



M. 

The red sweat that occurs in the axillae more especially, 
and elsewhere occasionally, is not a true chromidrosis, but 
is due to the growth of bacteria (micrococcus prodigiosus) 
upon the hair, as may readily be demonstrated under the 
microscope. The bacteria is sometimes present so abun- 
dantly as to encrust the hair. The same bacteria grown on 
culture media are colorless, and it is supposed that the 
action of the sweat upon them determines their color. At 
times not only are the hair and skin stained red, but also 
the underclothing is deeply dyed. 

A mild parasiticide ointment or oil with the use of soap 
and water, or a simple borax solution, will cure the disease 
just as in chromidrosis. 

Grreen sweat has been seen in workers in copper. Yellow 
sweat has been found associated with bacteria and without 
them. 

Chromophytosis 2 (Krom-o-fit-os'-iV). Synonyms: Pityri- 
asis versicolor ; Tinea versicolor ; Chloasma ; Mycosis micro- 
sporina ; (Ger.) Kleien Flechte ; (Fr.) Pityriasis parasitaire. 

A vegetable parasitic disease, characterized by brown or 
cafe-au-lait colored, variously shaped and sized patches that 
occur chiefly upon the trunk. 

1 Van Harlingen : Handbook of Skin Diseases. 

2 The name of chromophytosis was proposed for this disease by Dr. 
F. P. Foster, and has been well received in New York, as it quite 
accurately'defines the disease. 



112 DISEASES OF THE SKIN. 

This disease is far more common than statistical tables 
show it to be, as it causes so little trouble that many people 
never think of applying for relief. It begins as a small 
yellowish point, which rapidly grows into a split-pea-sized 
lesion. Many new lesions appear, and these coalescing, 
patches form which may be so large as to occupy a great 
part of the chest or back. At first, when of small size, the 
patches are circular in shape, but as they grow larger they 
lose all definiteness of shape, though their edges are always 
sharply marked and sometimes raised. Annular patches 
sometimes form, and at other times there will be many more 
or less circular patches of sound skin in the midst of the 
diffused patch. The color is usually fawn or cafe-au-lait ; it 
may be brown, or even black. The latter is reported only 
from tropical countries. In warm weather and in those who 
sweat profusely it is no uncommon thing to see the eruption 
present a pinkish hue, due to hyperemia of the skin. The 
edge of the patch may be somewhat raised, but the surface 
is not generally above that of the skin. It presents various 
appearances. At times it is smooth and feels greasy ; at 
times it is dry and covered with fine branny scales ; while 
at times it looks rough, and viewed from the proper light it 
presents an appearance resembling that of ichthyosis of mild 
grade. These appearances are dependent upon the amount 
of sweating, which, if profuse, will remove the scales, espe- 
cially if the clothing rubs upon the skin. The greasy feel 
is imparted by the oily sebaceous matter always marked in 
the region of the sternum, where chromophytosis most often 
is located. Whatever may be the apparent condition of the 
surface, scraping with the nail will remove a good part of 
the disease, showing that it is located in the upper layers of 
the epidermis. These patches are located chiefly upon the 
anterior surface of the chest and upon the abdomen. The 
back is also quite often affected, but not so markedly as the 
chest. In very extended cases the arms and legs may show 
the disease, and a few cases have been reported as occurring 
upon the face. The rule is that the uncovered parts of the 
body are spared, and exceptions to this are very rare. It 
is not symmetrical, The number of patches varies from a 
few to hundreds. 



CHROMOPHYTOSIS. 113 

The only subjective symptom is itching, and this is often 
absent, and seldom so bad as to cause the patient to seek 
relief on that account. Patients desire to be treated on 
account of the deformity, not the discomfort, of the disease. 

Etiology. The cause of the disease is the lodgment and 
growth in the corneous layer of the skin of a vegetable 
parasite, the microspor on furfur. Like all other parasites 
of its class, this one is incapable of growth on every skin, 
but does nourish especially upon the skin of one who sweats 
freely. That consumptives were thought to be especially 
prone to the disease is due to the fact that their chests are 
exposed to the physician more often than are those of any 
other class of patients. The disease is contagious, but its 
contagion is of low grade, and it is not common for it to 
take place even in such intimate relations as obtain between 
husband and wife. Adults from twenty to forty years of 
age are the most common subjects, though children have 
had the disease. According to Besnier and Doyon the dis- 
ease is never seen in very old people. It occurs in all coun- 
tries, but most often in hot climates. It attacks all classes 
and conditions of men, and shows no particular discrimina- 
tion in regard to sex. Its growth is interrupted by malarial 
paroxysms, and it peels off with the desquamation of 
scarlatina and measles. 

Pathology. The microspor on furfur is one of the most 
readily demonstrated of parasites. Place a few scales upon 
the slide, add a drop or two of liquor potassae, tease out the 
material a little, put on the cover-glass, and even with a low 
power the picture here represented will be seen (Fig. 10). 
It consists of heaps of conidra, which are larger than those 
of ringworm, with any quantity of interlacing mycelia run- 
ning between them. Free conidia are scattered about in the 
field. The fungus grows in the upper layers of the epidermis. 

Diagnosis. If one remembers the characteristic feat- 
ures of the disease, yellow or cafe-au-lait, scaly patches, 
that can be partly scraped away and are located chiefly 
upon the chest, little difficulty can arise in diagnosis. An 
appeal to the microscope will decide any doubtful question. 
Chloasma is not scaly, and cannot be scraped off from the 



114 



DISEASES OF THE SKIN. 



skin. Leucoderma is an absence of pigment with a hyper- 
pigmentation about it that comes up to the white spot with 
a concave border, and is not scaly. A fading erythematous 
syphilide occurs not in patches, but in isolated round macules 
that are neither scaly nor itchy, that are usually most 
numerous over the abdomen and sides of the chest, and 
that are very often found as a disseminated eruption occur- 
ring upon the face as well as the trunk. JErythrasma is 
not so scaly, and occurs only in or about the joints. Its 
parasite is much smaller than that of chromophytosis. 



Fig. 10. 




Treatment. Anything that will cause the removal of 
the upper layers of the epidermis will cure chromophytosis 
when present only to slight degree. But it is best for 
safety to use a parasiticide. One of the pleasantest ways 
of curing the disease is to have the patient scrub his skin 
thoroughly with soap and water, preferably soft-soap, and 
then dab on, twice a day, a solution of hyposulphite of soda, 
one drachm to the ounce. Sulphurous acid, pure or dilute, 



CLAVUS. 115 

is a prompt remedy. Vleminckx's solution, one to three or 
six parts of water ; bichloride of mercury, two or three 
grains to the ounce; sulphur ointment rubbed in thoroughly ; 
and tincture of veratrum viride, are efficacious. The danger 
of systemic poisoning by either the bichloride of mercury 
or the veratrum viride should deter us from using these 
remedies in extensive cases. Unna l recommends : 

R . Tinct. rhei aquosa?, | a _ M 

Brocq gives the following : 



13c. Acid, salicylici, 


2-3 parts. 


Sulphur, precip., 


10-15 " 


Lanolini, 


70 


Vaselini, 


18 



M. 

Chrysarobin, naphthol, boric acid, and resorcin, all are 
good. If the disease is very limited, it can be surely and 
speedily destroyed by painting the spot with tincture of 
iodine. 

There is only one point to be borne in mind in using any 
of these remedies, and that is that they must be thoroughly 
used, and continued for a time even after the last trace of 
the fungus seems to have been removed. If one spore is 
left behind, the disease is liable to return. Relapses are 
common, as the patient's skin is susceptible to the lodgment 
of the fungus. 

Cingulum. See Zoster. 

Clastothrix. See Trichorrhexis nodosa. 

Clavus (Kla'vu 3 s). Synonyms: (Fr.) Cor; (Ger.) Leich- 
dorn, Huhnerauge ; Corn. 

Symptoms. Corns are hyperplas ias of the corneous lay- 
ers of the skin due to pressure, and differing from calluses 
in having a central core that grows down toward the corium. 
They occur usually upon the toes, either over prominent 
joints, where they form hard corns, or between the toes, 
where, on account of being kept moist, they form soft corns. 

1 Vierteljahrschr. Derm. u. Syph., 1880, vii. 166. 



116 DISEASES OF THE SKIN. 

They are usually conical in shape and slightly projecting. 
Unless pared down they become painful by being pressed 
into the cutis. They are sometimes spontaneously painful 
on the approach of wet weather on account of their being 
hygroscopic. They may suppurate. They may occur upon 
the hands ; I have seen several cases in tennis-players. 

Treatment. The best treatment for corns is to wear 
well-fitting boots or shoes, which must not be too large or 
too small. The corn may be removed by the use of a sali- 
cylic acid plaster, or by Vigier's preparation, now sold in 
all the shops under the name of Hebra's Corn Remedy, 
which is composed of — 



Ac. salicylici, 


gr. xv. 


Ext. cannabis indica?, 


gr. viij. 


Alcoholis, 


Wxv. 


Etheris, 


Ttlxl. 


Collodion flex., 


mjxxv 



M. 

which is to be painted on three times a day for a week ; 
then the feet are to be soaked in hot water, and the corn 
picked out. They may also be cut out, but the operation 
is at times dangerous, especially in old people. Crocker 
recommends for soft corns careful daily ablution with soap 
and water, painting on them spirits of camphor at night, 
and wearing wool between the toes during the day. But 
unless well-made boots are worn, the corns will be sure to 
return. Corns on the hands may be removed with salicylic 
acid, or scraped out with the dermal curette. 

Cnidosis. See Urticaria. 

Colloid degeneration of the skin. Synonyms : Colloid 
milium ; (Ger.) Hyalom der Haut ; (Fr.) Hyalome cutane. 

Symptoms. This is a very rare disease of the skin that 
occurs most often on the upper part of the face in the form 
of disseminated or grouped, discrete, transparent, shining, 
rounded, lemon-yellow elevations of the skin. Though they 
look as though they were vesicles, they do not contain fluid, 
and when pricked give exit to only a small amount of 
gelatinous substance and a drop or two of blood. They 
are resistant to the touch. The course of the disease is 



COMEDO. 117 

slow. It is capable of spontaneous disappearance by ab- 
sorption or inflammation, leaving an ill-defined mark on the 
skin. It affects both sexes. The youngest patient so far 
reported was fifteen years old. There are no subjective 
symptoms, and the general health is good. 

Diagnosis. It differs from xanthoma in the transpa- 
rency and shining appearance of the lesions and in their 
lemon-yellow color. In xanthoma the lesions are soft and of 
a duller yellow. They may be removed with the curette. 

Comedo (Ko 2 m r e 2 d-o). Synonyms: Acne punctata, Acne 
follicularis ; (Fr.) Oomedon, Acne punctuee, Tanne ; (Grer.) 
Mitesser, Hautwiirmer ; Grubs, Fleshworms, Blackheads. 

A comedo is a collection of inspissated sebaceous matter 
retained in a pilo-sebaceous gland, whose mouth is closed 
by a black- topped plug of extraneous matter, and appears 
as a pin-point to a pin-head, slightly elevated, conical papule 
in the skin. 

Symptoms. Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wherever 
met with they present the characteristics indicated in the 
definition just given. They are unaccompanied by inflam- 
matory symptoms. Just as soon as inflammation is caused 
by their presence, they are converted into acne lesions — a 
change that they very commonly undergo. Usually they 
are scattered about irregularly ; sometimes they are grouped 
in certain regions. They are single lesions in the vast 
majority of cases, and being pressed between the thumb- 
nails they are readily expressed in the form of a filiform or 
worm-like mass that may be a half-inch or more in length, 
and has a black head, that obtains for them the popular 
name of " fleshworms." Very exceptionally they are 
double, lateral pressure squeezing out a filiform mass with a 
black head at both ends, if such an expression is allowable. 
There may be but few, or there may be hundreds of them 
so that the face looks as if full of grains of gunpowder. 
The largest are found in the ears and on the back. They 
give rise to no subjective symptoms. Seborrhoea oleosa is 
frequently a marked complication. 



118 DISEASES OF THE SKIN. 

In children they are more apt to be grouped, and, ac- 
cording to Crocker, to appear on the foreheads and occiputs 
of boys, the temples in girls, and the cheeks in infants. 
The scalp, too, is in them the seat of the disease. Acne 
may follow them. 

Etiology. All that has been said as to the causes of 
acne applies with equal force to comedones, and need not 
be repeated here. We would only add that Unna does not 
accept the commonly received doctrine that the black head 
and the clogging of the follicle are largely due to extra- 
neous matter, but teaches 1 that they are due to the corneous 
layer of the skin being abnormally firm, and preventing 
the escape of the follicle contents by growing over its mouth. 
The black color he believes to be analogous to the coloration 
of horns in cattle. He calls attention to the fact that 
comedones are more frequent in chlorotic girls than in coal- 
heavers. 

It is quite certain that many cases of comedones are 
directly due to dirt or other foreign matters stopping up the 
follicles. This is supposed to be especially the case in 
children. Colcott Fox 2 says that in them the comedones are 
found most often in the spring-time, and disappear in the 
winter. The youngest case in a child is one at twelve 
months. 3 

Pathology. The pathology of the affection is the same 
as that of acne without the evidence of inflammation. The 
demodex folliculorum, a harmless parasite, is very often 
found in the plugs of sebaceous matter. This is long and 
worm-like, with a head ; a thorax with four pairs of short, 
conical, three-jointed feet, with minute claw-like extremities, 
and a long tail-like abdomen, which tapers off into a blunt 
and rounded point. (Fig. 11.) 

Von During 4 has endeavored to show that the double 
comedo is always an acquired formation, and is the result 

1 Virchow's Archiv, 1880, lxxxii. 175. 

2 Lancet, 1888, i. 665. 

3 Crocker : Lancet, 1884, i. 704. 

4 Monatshefte f. p. Dermat., 1888, vii. 401. 



COMEDO 



119 



of a destructive process between the ducts of two neighbor- 
ing glands, so that the two ducts become one, and that the 
destructive process has affected only one gland, while the 
other one is still active enough to produce the comedo 
plug. 

Fig. 11. 




Demodex folliculorum. (After KUchknmeister.) 



Diagnosis. There is little difficulty in recognizing the 
disorder. Powder grains in the skin are under the skin, 
and cannot be squeezed out. 

Treatment. The same constitutional conditions being 
met with in comedones as in acne, we need not repeat here 
what was said there in regard to their general treatment. 

The local treatment consists in pressing out the come- 
dones, and stimulating the skin to a more healthy action. 
There is little use in doing the first without the second, as 



120 



DISEASES OF THE SKIN 



the comedo would be sure to re-form. The comedones come 
out most readily after the free use of soap and warm water. 
Then they may be pressed out between the thumb-nails, or 
by means of an old watch-key, whose sharp edges have been 
worn down ; or by means of either of the comedo-pressers 
of PifFard (Fig. 12), or the comedo-scoop of Fox (Fig. 13). 
With some practice they may be removed by pressing 




PifFard's comedo-extractors. 

the back side of a small dermal curette against one side of 
the follicle mouth, and making a quick turn of the end 
about them. Violent attempts at removal should not be 
made, as they may cause inflammation on account of 
too much irritation. If the comedo does not come out 
readily, wait until another time. 

Fig. 13. 



Fox's comedo-seoop. 



Frictions with green or soft soap and water are excellent 
as a stimulating remedy, care being taken not to set up too 
much reaction. Hardaway recommends : 



R . Saponis olivas preparat., \ 
Alcoholis, J 

Aquae rosse, 



aa 






16 
100 



M. 



To be rubbed in with a piece of dampened flannel every 
night. He regards the use of sulphur preparations as tend- 



CORNU CUTANEUM. 121 

ing to cause comedones, and hence objectionable. Alcoholic 
and astringent lotions, of boric acid, alum, or zinc, are 
useful. Unna in the paper already cited directs that the 
following — 

K • Kaolin, 4 parts. 

Glycerin, 3 " 

Aceti, 2 " M. 

be applied every night with the eyes closed. Sulphur and 
most of the preparations given under Acne have their advo- 
cates here. 

The best prophylactic measure is the daily washing of 
the face with soap and water. 

Condyloma. See Verruca and Syphilis. 

Congelatio. See Dermatitis calorica. 

Corn. See Clavus. 

Cornu Cutaneum vel Humanum. Synonyms : (Fr.) 
Corne de la peau ; (Ger.) Hauthorn ; Cutaneous horn. 

This is a rare disease of the skin, in which there grows 
a horn-like excrescence resembling, often in a most 
striking manner, an animal's horn. These vary greatly as 
to size. They may attain the length of a foot and a diameter 
of fourteen inches at the base, and are usually single, but may 
be multiple. They may be straight, but usually are bent 
or twisted; they may be laminated, striated, or fibrillated; 
they may be yellowish, dirty gray, green, brown, or black ; 
they are solid and hard, but not smooth and shining like 
animals' horns often are ; and they have rounded or truncated 
ends. They are not painful unless pressed on. When torn 
or knocked off they expose a raw and bleeding surface. 
Sometimes they fall spontaneously, or as the result of some 
inflammatory process. Most of them occur upon the head, 
nose, face, or scalp. They may occur elsewhere, as upon 
the extremities, or male genitals. Their bases may become 
the site of epithelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. 

Treatment. The treatment consists in tearing them off, 

6 



122 DISEASES OF THE SKIN. 

under an anaesthetic if large, curetting the base, and apply- 
ing a caustic agent, such as a zinc paste or pyrogallic 
acid. 

Couperose. See Rosacea. 

Crasses Parasitaires. See Chromophytosis. 

Crusta Lactea. See Eczema. 

Cutis Anserina, or Goose-flesh, is that condition of the 
skin in which, on account of the action of cold causing a 
contraction of the arrectores pilorum muscles and elevation of 
the hair follicles, it feels rough, and looks as if studded over 
with minute papules. It is a fugitive affair, therein differ- 
ing from keratosis pilaris, which, though resembling it, is 
constant. 

Cutis Pendula. See Dermatolysis. 

Cutis Tensa Chronica. See Scleroderma. 

Cutis Unctuosa. See Seborrhcea. 

Cyanosis (Si-a 2 n-os r i 2 s) is a bluish coloration of the skin 
from defective aeration of the blood, either temporary, as in 
asphyxia, collapse, etc., or permanent, as in the subject of 
some malformation of the heart, especially persistent patency 
of the foramen ovale. 1 

Cysticercus Cellulosae Cutis. At times the larvae of the 
tapeworm become lodged in the subcutaneous tissues, and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 
smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals die, 
and the tumors shrivel up and become hard nodules, or they 
may be absorbed. They simulate gummas, lipomas, sar- 
comas, carcinomas, and sebaceous cysts. In a doubtful 
case excision or puncture of one of the tumors will show us 
under the microscope either one of the larvae curled up in 
its shell, as it were, or the hooklets in the fluid that 
escapes. 

Cysto-adenoma is an adenoma containing cysts. 

1 Foster's Encyclopaedic Medical Dictionary. 



DERMATALGIA. 123 

Dandriff or Dandruff. See Seborrhoea. 

Dartre Farineuses, Furfuracees, or Volantes. Old terms 
for Pityriasis and Eczema. 

Dartre Rongeante. See Lupus vulgaris. 

Dartrous Diathesis. This term, though still used by 
French writers, is of very indefinite meaning, and has been 
dropped by their latest author, Brocq, Dunglison defines 
it as " a peculiar state of health, which renders its subject 
liable to general eruptions of different forms, which are 
always met with in the young, are symmetrical, and con- 
trolled by arsenic." It is supposed to be the underlying 
cause of eczema, herpes, seborrhoea, psoriasis, and not a few 
other diseases. 

Decrepitude Infantile. See Sclerema neonatorum. 

Defluvium Capillorum. See Alopecia. 

Defcedatio Unguium. See Nails, degeneration of. 

Delhi Boil. See Aleppo boil. 

Dermalgia. See Dermatalgia. 

Dermatalgia .(Du 5 rm-a 2 t-a 2 l'ji 2 -a 3 ). Synonyms: (Fr.) 
Dermalgie ; (Ger.) Hautschmerz, Hautuervenschmerz ; Neu- 
ralgia or rheumatism of the skin. 

By this term is meant spontaneous pain in the skin, with- 
out any appreciable alteration of the same. The pain is 
variously described by patients, as boring, pricking, or 
burning ; or numbness or coldness may be complained of. 
It is constant or intermittent in character, and sometimes so 
severe as to be agonizing. It is generally sharply located 
to a certain place, but it may be general. The hairy parts 
are those most often affected, as the scalp. The legs and 
back, palms and soles, are also not infrequently involved, as 
may be any part. Hypersesthesia or anaesthesia may be 
present at the same time. Deep pressure may or may not 
relieve it. It disappears of itself after weeks or months. 

Etiology It is a neurosis that may be idiopathic or 
symptomatic. The idiopathic form is rare, and its etiology 
obscure. The symptomatic form occurs in locomotor ataxia, 



124 DISEASES OF THE SKIN". 

rheumatism, syphilis, malaria, diabetes, hysteria, and chlo- 
rosis. According to Hyde it may be a sign of the approach- 
ing menopause. The majority of its subjects are women. 

Diagnosis. Dermatalgia differs from neuralgia in being 
more superficial and in being accompanied by hyperesthesia. 
It differs from hyperesthesia by being a spontaneous pain, 
while the latter is pain only upon contact. 

Treatment. If we can remove the underlying cause we 
shall cure the trouble, so our remedies should be first ad- 
dressed to it. Unfortunately, for some of the diseases of 
which dermatalgia is a symptom we can do little. In any 
case, the patient demands some local treatment to relieve 
the pain. In the way of internal remedies we can use 
salicylate of soda, quinine, antipyrin, phenacetine, some 
form of opium, hyoscyamus, valerian, and other like drugs. 
Externally, relief may be obtained by galvanism, blistering, 
a mustard leaf over the centre from which emanates the 
nerve (Crocker), hot or cold water in a rubber water-bag, 
either alone or alternately ; rubbing in Squibb's oleate of 
mercury or morphine, menthol pencil, chloroform liniment, 
tincture of aconite, and the like. 

Dermatite Exfoliatrice Generalisee. See Dermatitis ex- 
foliativa. 

Dermatitis (Du 5 rm-a 2 t-i , -ti 2 s). This word means simply 
inflammation of the skin, and would, therefore, cover all 
diseases of the skin that are of inflammatory nature. But 
it is applied to those diseases of the integument that are 
simple inflammations, and due to the action of external 
irritants. They are all marked by redness, swelling, and 
heat. The name dermatitis, with a qualifying adjective, is 
also applied to diseases other than those in this section, as 
will be seen further on. 

Dermatitis Calorica is the inflammation of the skin pro- 
duced by heat or cold, and divides itself naturally into two 
divisions, viz : D. ambustionis and D. congelationis. 

Dermatitis ambustionis is the effect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and pro- 



DERMATITIS. 125 

longed action of the heat and the resistance of the skin will 
be the damage inflicted on the skin. A slight degree of 
heat gives rise to a passing erythema. Burns are due to a 
greater amount of heat, and are described for convenience 
as being of three degrees. In the first degree the skin is 
reddened, hot, and somewhat swollen ; in the second, the 
damage is greater, and we have the production of vesicles 
and bullae ; and in the third, there is complete destruction 
of the skin, followed by gangrene. Extensive burns may be 
dangerous to life even if not of very high degree, and burns 
involving one-half the cutaneous surface are generally fatal. 
The cause of death in such cases is uncertain. The latest 
theory, as put forth by Lustgarten, 1 is that it is due to a 
toxine developed by the lodgment of microorganisms of 
putrefaction upon the eschar, probably a ptomaine similar 
to muscarin. Some of the other theories are nerve-shock, 
ulcerations of digestive tract, nephritis, decomposition of the 
red blood-globules ; but no one of these is satisfactory in all 
cases. 

Treatment. The treatment of burns commonly falls 
into the hands of the surgeons. In simple burns Carron 
oil, consisting of equal parts of linseed oil and lime-water, 
to which may be added 5 per cent, of carbolic acid, applied 
by means of saturating absorbent cotton in it, and then cover- 
ing it with impermeable rubber tissue, forms an admirable 
dressing that may be left on for several days, if care is taken 
to thoroughly disinfect the part before applying it. If this 
is not at hand, the part should be dusted thickly with flour 
or corn-starch until it is procured. Or the burns may be 
covered with a varnish of linseed oil and wax, containing 5 
per cent, of salicylic acid. Or they may be powdered with 
bicarbonate of soda or any of the antiseptic powders. Deep 
and extensive burns must be treated on surgical and strictly 
antiseptic principles. Lustgarten, in the paper referred to, 
recommends the administration of atropine as a physiological 
antagonist to the ptomaine, the removal of necrotic portions 
of skin, and dressing the wound with carbonate of mag- 

1 Med, Bee., 1891, xl. 152, 



126 DISEASES OF THE SKIN. 

nesia, 1 part, and oleum rusci, 2 parts. All cases of any 
magnitude demand absolute rest in bed. The continuous 
water-bath of Hebra is excellent where it can be had. 

Dermatitis congelationis or " frostbite " is the action 
of cold upon the skin. Like heat, cold produces varying 
degrees of damage to the skin; if not very intense, the effect 
is an erythema — "erythema pernio," "chilblain" — which 
is passing. These are seen upon the hands, feet, and face 
as bluish or purplish-red, circumscribed patches, which are 
cool to the touch, but are accompanied by a feeling of heat, 
smarting, or burning, both while forming and when the 
parts again become warmed. To those predisposed to chil- 
blains, dampness accompanied by only very moderately cool 
temperature is sufficient to produce them. Hutchinson 
speaks of the chilblain diathesis to indicate the condition 
found in these people. Their circulation is poor, and they 
are anaemic. Greater degrees of cold or longer exposure 
may produce bullae and vesicles, or gangrene, either on 
account of prolonged anaemia or inflammatory reaction from 
too sudden warming. Fingers, toes, nose, or ears may be 
lost in consequence, mortification setting in. Death may 
result from septicaemia. 

Treatment. The best preventive treatment of chilblains 
is the wearing of warm woollen coverings to the affected 
parts, and endeavoring to improve the general health of the 
patient and to quicken his circulation. To the latter end 
we may use warm foot-baths, containing salt, at night, fol- 
lowed by frictions with alcohol. When they occur stimula- 
tion is necessary, for which we may use iodine, either in 
tincture or ointment ; or equal parts of camphor and bella- 
donna liniment ; or — 

R. 01. cajiputi, \ .. 8 | 

Liq. ammon. fort., J ° J ' 

Sapo. liniment, co., ^iij ; 100 1 M. 

or simple frictions. Care should be taken in severe frost- 
bites not to allow the parts to become warm too rapidly, 
and nothing is better than rubbing them with snow, if that 
can be obtained, while the patient js kept in a cool room. 



Dermatitis. 127 

When sloughing or ulceration is begun it must be treated 
on surgical principles. 

Dermatitis Traumatica. This term is used to comprise 
all inflammations of the skin that are due to traumatic 
influences, such as blows, rubbing, and the like. It pre- 
sents the usual signs of inflammation to a greater or less 
extent, according to the degree of traumatism and the sus- 
ceptibility of the individual skin. The irritation of the 
skin, due to scratching, is a common instance of this form 
of dermatitis. Under certain circumstances it easily de- 
velops into an eczema. The chafing of the skin met with 
in horseback-riding, in those unaccustomed to the exercise, 
is another common instance. 

Treatment. The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting pow- 
ders, alkaline lotions, or mild ointments, such as that of the 
oxide of zinc. Unna 1 recommends for the prevention of the 
dermatitis due to horseback-riding, that the parts should 
be smeared over with a weak resorcin or ichthyol ointment. 

Dermatitis Venenata. Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of 
small, closely crowded together vesicles that may remain 
isolated or run together and form bullae, are the symptoms 
that constitute this form of dermatitis, the cause of which 
is always some sort of irritant applied to the skin. The 
irritant is usually of a chemical nature, and quite commonly 
is derived from plants. The most frequent cause is contact 
of the susceptible skin with the leaves of the rhus toxico- 
dendron, the poison-ivy, and the rhus venenata, the poison- 
sumach, and the rhus diversiloba, the poison-oak. Dr. 
James C. White, 2 of Boston, has written a most complete 
and learned w T ork on the subject, and it is to this that the 
reader is referred for a more detailed account of the disease 
than can be here given. The mildest degree of irritation 
is an erythema. Commonly the action is more marked. 
The patient first experiences a little burning or itching, and 

1 Monatshefte f. prakt. Dermat., 1888, No. 21. 

2 Dermatitis Venenata, Boston, 1887. 



128 



DISEASES OF THE SKIN. 



attention being drawn to the part it is found to be reddened 
and swollen. In some cases we may have wheals. In a few 
hours papules, and then vesicles, will form, and perhaps 
bullse. The swelling may be intense, so as, on the face, to 
completely close the eyes. I have seen it so great on the 

Fig. 14. 




Dermatitis venenata from poison-ivy. 1 

scrotum as to give the appearance of an immense hydrocele. 
The vesicles may be present in a countless multitude. The 
acute developing symptoms may last several days, and 
then gradually subside. The vesicle contents either dry 
up or discharge upon the skin. The parts crust, the 

1 From a photograph by Dr. H. W. Blanc, of New Orleans. 



DERMATITIS. 129 

swelling and redness slowly disappear, and the skin once 
more becomes normal. The cause of the trouble is supposed 
to be toxicodendric acid. The parts most usually affected 
are the hands and face in both sexes, the penis in the male 
and the breasts in the female ; that is, those parts that come 
in direct contact with the poison, or to which it is most lia- 
ble to be conveyed by the hands. In some rare cases, and 
in extremely sensitive individuals, the whole body may be 
affected, and there may be grave constitutional disturbances. 
These bad cases are met with in children whose legs are un- 
covered. Most persons, perhaps, are not susceptible to the 
poison. Some few are so susceptible that even having the 
wind blow on them from over one of the plants will set up 
the dermatitis. 

It is probably not true that the dermatitis will relapse 
after an interval of time, but it has been observed that an 
eczema may follow the dermatitis, and that this may show a 
certain amount of periodicity in its outbreaks. White says 
that while the poison may be most active in the flowering 
season, it is sufficiently active at all seasons, and that the 
poison resides not only in the leaves but also in the wood, 
bark, and fruit. The disease is not contagious after the 
parts have been well washed. 

Diagnosis. The eruption differs from that of eczema by 
seeking the inner sides of the fingers, the hands, face, 
breasts, and genitals ; by the greater amount of swelling 
that commonly attends it ; by the vast number of crowded 
together, " lurid " vesicles ; and by the occasional occur- 
rence of the eruption in its early stage in streaks, sugges- 
tive of striking against the plant. A history of having 
been in the country will sometimes be an aid in diagnosis. 

Treatment. The disease is a self-limited one. It is, 
therefore, natural that there are many " sure cures " for it, 
and nearly every section of the country has some popular 
remedy. Lime-water, that can be procured anywhere, will 
afford relief as promptly as anything. The parts are to be 
kept constantly covered with lint or absorbent cotton con- 
tinuously saturated with it. At night we cannot use this if 
the patient sleeps, as the cotton or the lint dries. So it is 

6* 



130 DISEASES OF THE SKIN. 

better at this time to use some simple ointment, as cold cream, 
oxide of zinc, or diachylon diluted one-half. This treatment 
commends itself on account of its efficacy, cheapness, safety, 
and accessibility. White recommends black wash (calomel, 
5j ; aq. calcis, Oj), applied for half an hour at a time, two 
or three times a day. He cautions against the danger of 
using it in extensive cases. As a substitute for it he gives : 



R. Zinci oxid., 3iv; 16 

Ac. carbol., gj ; 4 

Aq. calcis, Oj ; 500 



M. 



Sugar of lead in solution is a well-known remedy, and 
efficacious, but dangerous. Morrow 1 recommends : 

Be. Sodii hyposulphitis, ,^j ; 25! 

Glycerini, 5ss; 12 

Aquae, ad J viij ; 200 M. 

S. Kept constantly applied. 

After the acute stage has passed the case should be treated 
like an eczema. If the constitutional disturbance is marked, 
the patient should be cared for upon general medical prin- 
ciples. 

While the poison-oak, or ivy, causes the symptoms most 
often spoken of as dermatitis venenata, there are a number 
of other plants that will produce like, if not as severe, symp- 
toms. Of the commoner ones we find the oleander, Jack-in- 
pulpit, skunk cabbage, bitter orange, May-apple, arnica, 
burdock, golden rod, and common daisy. But space will 
not allow of a complete list of these. Goa powder and its 
derivative, chrysarobin, produce a marked dermatitis in addi- 
tion to their mahogany-staining of the skin. The action of 
croton oil, mustard, stinging nettle, and oil of turpentine is 
well known. Tar may excite a general dermatitis or an 
acne-like inflammation of the follicles called "tar acne," 
the follicles of the skin being stopped up and their mouths 
filled with a black plug of tar. A somewhat similar eruption 
is seen in workers in flax and paraffin. 

A great number of chemicals produce dermatitis of vary- 
ing degree. Pyrogallic acid produces burning and inflam- 

1 Journ. Cutan. and Yen. Dis., June, 1886. 



DERMATITIS EPIDEMICA. 131 

mation, and covers the part with a black coating on account 
of its oxidation. Not only does it destroy diseased tissues, 
but it may cause sloughing of the sound skin. Chloro- 
form will blister if prevented from evaporation. This pecu- 
liarity is sometimes employed for vesication. The strong 
acids destroy the skin, as also arsenic. Sulphur, iodine, 
iodoform, creolin, mercurial preparations, chloride of zinc, 
bichromate of potash, and potassa cause varying degrees of 
dermatitis. Electricity will redden and inflame the skin, 
and not a few cases of dermatitis have resulted from wear- 
ing clothing dyed with aniline dyes. 

Dermatitis Contusiformis. See Erythema nodosum. 

Dermatitis Epidemica. Under this name Savill 1 has re- 
ported the occurence, in Paddington Infirmary, of a num- 
ber of cases of an apparently contagious disease of the skin, 
that began either as a discrete papular eruption, or as ery- 
thematous blotches like erythema nodosum or papulosum, 
or as small, flat papules enlarging at the periphery and 
spreading like ringworm. This stage lasted three to eight 
days. It was followed by the second stage, which was one 
of exudation or desquamation, and lasted three to eight 
weeks. However the disease began, the lesions soon ran to- 
gether and formed a crimson surface of thickened and indu- 
ated skin, continually shedding its cuticle in scales or flakes 
of various sizes, sometimes mingled with drier exudation. 
In the second stage it assumed either a moist type like 
eczema madidans, or a dry one like pityriasis rubra. About 
two-thirds of the cases were of the moist variety, and almost 
all at some period showed slight moisture, either in the 
flexures of the joints or behind the ears. Continuous ex- 
foliation was present in all the cases. 

The third stage was one of subsidence. By degrees the 
inflammation lessened, leaving an indurated, thickened skin, 
with polished brown appearance, which was sometimes raw, 
or parchment-like, smooth and shiny, or cracked, or pur- 
puric, especially in aged people. 

The disease began most often in the skin-folds of the face 

1 Brit. Journ. Dermat., 1892, iv. 35. 



132 DISEASES OF THE SKIN. 

and upper extremities, and involved either the whole body 
or limited areas. It generally spread by continuity. The 
hair and nails were all shed. 

The constitutional symptoms were anorexia and prostra- 
tion. There was either no change in the body temperature 
or a slight rise in the evening during the height of the dis- 
ease. Itching and burning were marked, and there was 
considerable suffering experienced in those cases in which 
the epidermis was shed. Relapses were frequent. Albu- 
minuria was found in half of the cases, and death occurred 
in about twelve and four-fifths of the cases. 

More men than women were attacked, and advanced age 
predisposed to it. A specific microorganism is thought to 
have been found in it. 

It seems to me that these cases were but dermatitis ex- 
foliativa, as we understand it in this country, instances of 
the contagion of which I have once met with. Its proper 
place has not been determined as yet. 

Dermatitis Exfoliativa. Synonyms : Pityriasis rubra 
(Devergie and Hebra) ; Eczema foliaceum seu exfoliativum ; 
(Fr.) Dermatite exfoliatrice ou exfoliative generalised, Herpe- 
tides exfoliatives, Erythrodermies exfoliantes. 

An inflammatory disease of the skin involving the whole 
cutaneous surface, and characterized by redness, dryness, 
and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra are 
used interchangeably by most authorities of the present time. 
If one reads the description of pityriasis rubra, as given 
by Hebra, and of dermatitis exfoliativa, as given by Wil- 
son, he will find that the chief difference between them is 
in prognosis, the first being spoken of as uniformly fatal, 
and the second as tending to recovery in many instances. 
Further, there are not a few cases of general exfoliating 
dermatitis that follow psoriasis, eczema, pemphigus folia- 
ceus, and lichen ruber, that present symptoms identical 
with those of dermatitis exfoliativa, without antecedent 
disease. It seems justifiable, therefore, to divide derma- 
titis exfoliativa into two varieties, namely, a primary and a 
secondary. 



DERMATITIS EXFOLIATIVA. 133 

1. Primary Dermatitis exfoliativa or Pityriasis rubra of 
Hebra. 

Symptoms. This disease begins as one or more erythe- 
matous patches in the folds of the joints, upon the upper part 
of the chest, or elsewhere, and these patches gradually en- 
large. At the same time new patches develop, and increas- 
ing in size join the original ones. In this way the whole 
surface may become red within three days, or a month or 
more may elapse before the whole surface is implicated. 
The palms and soles may be unaffected for days or weeks. 
The skin is dry, and of a bright red at first, without thick- 
ening and infiltration, the redness lessening and leaving a 
yellow stain on pressure. In a few days, say from six to 
twelve, scaling begins, and the skin becomes of a darker- 
red ; it may even become violaceous. The scales may be 
large, thin, grayish, attached at their upper border, and 
loose elsewhere, being turned up at their edges. They may 
be small and adherent in the centre. The amount of scaling 
is so great that handfuls of scales may be gathered. After 
a few weeks the epidermis is raised and shed from the hands 
and soles in the form of a continuous sheet, sometimes form- 
ing a complete cast of the part. The disease is chronic, and 
the scaling constant, though marked with exacerbations. 
After lasting some time, there is a certain amount of infil- 
tration of the skin, and it seems to grow too small for the 
body, and looks stretched and shiny in places. Thus are 
produced ectropion and a puckered condition of the mouth. 
We may also find cracking about the joints and moisture 
in these regions. Furuncles, bullae, or pustules may com- 
plicate matters. The hair may be shed from all parts, and 
the nails become raised from their beds and shed. The 
mucous membranes participate in the disturbance, the tongue 
becomes markedly red, the lips cracked, and the nasal secre- 
tions are increased. With the ectropion there is conjunc- 
tivitis. 

The disease begins, in some cases, with a chill, followed 
by a fever, that may rise to 104° F. Fever is present in 
allcases during the early period, and may continue through- 
out. It is sometimes continuous, with evening exacerba- 



134 DISEASES OF THE SKIN. 

tions ; at other times it is only at night. Diarrhoea often 
is met with, and there may be vomiting, albuminuria, and 
pulmonary congestion. The patient complains of a feeling 
of chilliness, and of pain, tenderness, stinging, burning, or 
tingling of the skin. There is usually no itching. The sensi- 
bility of the skin is preserved, and the secretion of sweat may 
be normal, or lessened, or increased. The duration is very 
variable. Recovery may take place in six months or a 
year, or the course may be chronic, the patient dying either 
in a few months or after years by a gradual marasmus, though 
the end is usually hastened by pulmonary complications. 

Cases of localized dermatitis exfoliativa have been re- 
ported, but they are rare. The tendency is for the disease 
to become general, though it may take years to do so. Cases 
of a recurrent type have been met with. 

Etiology. We know very little about the causes of the 
disease. It is a disease of adults, and more common in men 
than in women. It may occur in children. It has been 
thought to be predisposed to by alcoholism, gout, and rheu- 
matism. There may be a history of scaling skin diseases 
in the family. At present we cannot speak with any cer- 
tainty as to its etiology. 

2. Secondary Dermatitis exfoliativa. A condition of 
the skin exactly resembling the primary form is seen from 
time to time to follow upon or develop from a psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber. I have 
seen one case follow lichen planus. The too vigorous use 
of chrysarobin has been known to be followed by it. These 
cases differ from the primary form only in their antecedent 
skin disease. Once developed they run the same course as 
the primary form, either becoming well quickly, or falling 
into a chronic state from which recovery may or may not 
take place. The prognosis is, however, much better in the 
secondary than in the primary form. 

Pathology. Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when it 
has lasted some time the whole depth of the skin is involved, 
and eventually there is new connective-tissue formation, which 
subsequently undergoes cicatricial contraction, with abundant 



DERMATITIS EXFOLIATIVA. 135 

pigmentation, hyperplasia of the elastic fibre bundles, and 
obliteration of the skin appendages. (Crocker.) 

Diagnosis. When the features of the disease, as laid 
down in the definition, are remembered, there should be no 
difficulty in recognizing it. No other disease involves the 
whole surface in a uniform dry and scaling redness. It dif- 
fers from psoriasis in being universal, in an entire absence 
of thick, silvery- white scales, and in leaving a smooth, red 
surface when its papery scales are removed. Should it be 
secondary to a psoriasis, there will be no difficulty in ob- 
taining a history of that disease. It differs from eczema in 
being a dry disease, with little infiltration, in its large papery 
scales, and in itching but slightly. Eczema may be almost 
universal, but some places are apt to be spared ; there 
is always moisture of a sticky sort present somewhere, or a 
history of the same ; its scales are small, and its itching in- 
tense. It differs from pemphigus foliaeeus in an absence 
of flaccid bullae. It differs from lichen ruber in an entire 
absence of papules, and in the whole course of the disease. 
All these diseases may be general, but it is exceedingly rare 
for them to become universal, and it is always possible to 
obtain a history of their having been present at some time 
in a case of secondary dermatitis exfoliativa. It is hardly 
likely that scarlatina could be confounded with dermatitis. 
A few days' watching would in any event decide the ques- 
tion. 

Treatment. The results of treatment of this disease 
leave much to be desired. Many internal and external 
remedies have been tried, but they all are of very uncertain 
value. There is no doubt but that the patient is most 
comfortable when the skin is well oiled, and vaseline of 
good quality answers well for this purpose. The general 
health is to be watched over, iron and quinine administered, 
and care exercised to preserve the strength by judicious 
feeding without stimulation. Diuretics may be given with 
the idea of relieving the congestion of the skin. Carbolic 
acid has been recommended, but in my hands proved worse 
than useless in one case. Pilocarpine, or jaborandi, is rec- 
ommended by Hardaway in acute cases. Arsenic should 



136 . DISEASES OF THE SKIN. 

not be given till late in the disease, if at all. Crocker recom- 
mends enveloping the body in calamine lotion, and bicar- 
bonate of potash is given every four hours in twenty-grain 
doses, with twelve grains of citric acid and three to five 
grains of quinine, the whole taken while effervescing. Sher- 
well has reported several cases cured by the continuous use 
of linseed oil, both internally and externally. The patient 
is to chew or take in milk several ounces of flaxseed in 
twenty-four hours. He is to be kept in bed with a rubber 
sheet under him, and to be saturated, as it were, in crude 
linseed oil. If the oil is not used abundantly it is worse 
than useless. 

Dermatitis Exfoliativa Neonatorum is a disease of new- 
born children, first described by Ritter von Rittershain, 1 
and said by him to be quite often seen in the foundling asy- 
lums of Prague. 

Symptoms. It begins at the mouth as an erythema, and 
thence spreads to the trunk and extremities. Then the 
epidermis raises itself from the cutis, rumples, and sponta- 
neously exfoliates in large folds, leaving a dry skin, or there 
may be exudation under the epidermis. It lasts seven to 
eight days, and begins usually between the second and fifth 
w r eek of life. Relapses may occur. There is no fever, nor 
digestive disturbances. Furuncles, abscesses, or phlegmonous 
infiltration, with gangrenous destruction, may follow. Re- 
covery takes place in about half the cases. It is supposed 
to be a pysemic condition of the skin. Other cases have 
been reported. 

Treatment. Alkaline lotions will prove beneficial in the 
early stage. Later, a protecting ointment, such as that of 
oxide of zinc, or simple vaseline, followed by corn-starch, 
will be indicated. 

Dermatite Exfoliative Aigue Benigne. See Erythema 
scarlatiniforme. 

Dermatitis Gangrenosa or Sphaceloderma. Gangrene 
of the skin may be due to a great variety of causes. Many 

1 Archiv. f. Kinderheilkunde, 1880, i. 53. 



DERMATITIS GANGRENOSA. 137 

cases are due to purely local causes, such as burns, bruises, 
compression, chemical action, and the like. It is seen in 
the course of diabetes, albuminuria, and some cardiac dis- 
eases ; with degenerative changes taking place in the vascular 
walls of arteries, or plugging of their lumen ; and in con- 
nection with other skin diseases, as carbuncle. Besides these 
we have a group of little-understood cases of gangrene, due, 
apparently, to nervous influences, and occurring in connection 
with diseases of the nervous system. These may occur any- 
where, and may be superficial or deep. They behave like 
surgical gangrene,and are to be treated on the same principles. 
It is always to be borne in mind that gangrene occurring in 
hysterical women is apt to be self-imposed. If such cases 
are carefully noted, it will be observed that the spots appear 
where they can be most readily reached by the patient's 
right hand, or left, if she be left-handed. A case of that 
sort was recently seen by me, which rapidly became well as 
soon as I told the girl that she knew the cause of the trouble 
as well as I did, and need have no more of it unless she 
wished. 

There are two forms of cutaneous gangrene that have re- 
ceived special names that must be noticed here. They are : 
1. Symmetrical gangrene or Raynaud's disease; and, 2. 
Dermatitis gangrenosa infantum. 

1. Symmetrical G-angrene. This was first described by 
Maurice Raynaud, 1 and since then has been observed by 
others, although it is a very rare disease. It most often 
attacks the second and third phalanges of the fingers and 
toes ; next most frequently the nose and ears ; but any part 
may be attacked. The parts become pale and hard, and 
then swell. They feel numb, but the patient may experi- 
ence darting or stabbing pains in them. After a time, hours 
or weeks, they become black, a line of demarcation forms, 
and separation of the affected skin takes place. The process 
may stop short of the complete destruction of the part, and 
recovery may take place, though relapses are liable to occur. 
The disease is symmetrical. It may involve all four ex- 

1 These de Paris, 1862. 



138 DISEASES OF THE SKIN. 

treuiities, but usually only two are affected. Bullae may 
form. The nails may fall. 

Etiology. Men are more often affected than women. 
People of all ages are liable to it. Exposure to cold seems 
to be a causative factor, and not a few of its victims have 
been subject to chilblains or other symptoms of poor circu- 
lation. The malarial cachexia and the gouty habit have 
been supposed to be predisposing causes. It is probably of 
neurotic origin. 

Treatment. The internal treatment that has done best 
has been the administration of quinine and belladonna. 
Locally, galvanism may be tried, as it has done good. Cold 
applications are said to be better than hot. If gangrene 
has occurred it must be treated on surgical principles. 

Prognosis. The outlook is not good. Death may result 
in those who are not robust. Even if one attack is recov- 
ered from, another is apt to occur. 

2. Dermatitis G-angrcenosa Infantum (Crocker). Syno- 
nyms : Varicella gangraenosa (Hutchinson) : Pemphigus 
gangraenosus (Stokes) ; Rupia escharotica (Fagge) ; Ecthyma 
infantile gangreneux (Pineau) ; Gangrenes multiples ca- 
chectiques de la peau ; Ecthyma terebrant de l'enfance 
(Baudouin). 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 
after other diseases of the skin in children. It consists 
essentially in the formation of deep or superficial round or 
oval ulcerations beneath a black slough, and following upon 
a varicella or other pustule. The lesion when fully formed 
may be one inch or more in diameter, and three-quarters of 
an inch deep. The wider the slough, the deeper is the 
ulcer. Around the slough is a red areola. Crocker says 
that if the gangrene occurs while the varicella is still 
present, it begins on the head or upper part of the body, 
and then looks like a vaccination pustule ; while if it begins 
late in the course of the disease, the lesions will be located 
on the lower half of the body, especially the buttocks and 
thighs. In the latter cases the affected parts are riddled 
with ulcers of all sizes, shapes, and depths. If several 



DERMATITIS HERPETIFORMIS 139 

ulcers run together, very large and irregular ones may form. 
If the lesions are extensive or numerous, they may cause 
death very frequently by pulmonary complications. 

Etiology. Infants and young children under three years 
of age are those affected by this disease, and most of them 
are girls. Debilitating diseases, such as congenital syphilis, 
tuberculosis, and scrofula so called, predispose to the dis- 
ease. In my service at the Infants' Hospital on Randall's 
Island cases of this sort are not infrequent. In an epidemic 
of varicella, occurring in 1890, two cases were met with, 
one quite extensive upon the upper part of the back. The 
children received in the institution are from the lowest dregs 
of. our population, and the disease seems to be a product of 
several dyscrasic conditions plus a possible microbic in- 
fection. 

Treatment. The cases are to be managed upon general 
principles. Tonics, fresh air, good food, and hygienic 
surroundings, and remedies addressed as far as may be to 
the underlying constitutional condition are the best means 
for combating the disease. Crocker recommends quinine 
and sulpho-carbolate of soda, five grains every three hours. 
Locally, the Randall's Island cases were treated with iodo- 
form and antiseptic dressings. Aristol would probably 
answer well. 

Prognosis. The prognosis is not good in bad cases. 
Death is apt to result from lung complications, or pyaemic 
infection. 

Dermatitis Herpetiformis. This name was first suggested 
by Duhring, 1 of Philadelphia, for a composite disease which 
is characterized by great multiformity, marked grouping 
of the lesions ; by pruritus of varying intensity ; by chron- 
icity of course ; and by a strong tendency to relapse. 
Under it he includes the herpes impetiginiformis of Hebra, 
the hydroa of Bazin and Tilbury Fox, the herpes phlyctse- 
nodes of Gibert, the herpes gestationis of Bulkley, pem- 
phigus pruriginosus and circinatus, pemphigus a petites bulle, 
hydroa bulleux, and the herpes circinatus of Wilson. 

1 Journ. Anier. Med. Assoc, 1884, iii. 225. 



140 DISEASES OF THE SKIN. 

Though the name has been adopted by many, the exact 
status of the disease has not been settled. I shall give 
Duhring's account of the disease, space not allowing of a 
discussion of the subject. 

Symptoms. In severe cases there may be prodromata 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or 
these alternating, and itching. In mild cases these are 
absent. The onset of the disease may be gradual or sudden 
— the latter not infrequently. It may be diffused over the 
greater part of the general surface, or it may be in localized 
patches. Itching and burning, which is severe, precedes or 
accompanies the outbreak. It may begin as an erythema- 
tous, vesicular, bullous, pustular, or papular eruption, or 
by a combination of two or more of these, the multiformity 
being a characteristic. It shows a tendency for one variety 
of lesion to pass over into another, either during the attack 
or at some relapse. The relapses occur at intervals of 
weeks or months. All regions are invaded, the course is 
essentially chronic, and in pronounced old cases the skin is 
excoriated and pigmented. The mucous membranes may 
be involved. 

Dermatitis herpetiformis erythematosa. This form is 
usually of urticarial or erythema-multiforme type, and occurs 
either in patches or diffused. The circumscribed patches 
may coalesce and form larger patches with marginate out- 
line. The color varies with the age of the lesion, becoming 
darker with age. There may be maculo-papules, flat in- 
filtrations, or vesico-papules. It may continue in this way 
for days or weeks, but usually it changes to the multiform 
type. There is pruritus. 

Dermatitis herpetiformis vesiculosa. This is the form 
most usually met with. The vesicles are from pin-head to 
pea-sized, flat or raised, irregular or stellate in shape, glis- 
tening, pale-yellow or pearly, firm, tensely distended, and 
without areola. There may be papules, papulo-vesicles, 
vesico-pustules, and sometimes bullae. The lesions are dis- 
seminated, but aggregated into clusters of two, three, or 
more, or may form groups as large as a silver dollar. If 



DERMATITIS HERPETIFORMIS. 141 

the vesicles are near together, they tend to run together 
and form blebs, which are raised and surrounded by a pale 
or distinct red areola, and of a puckered or drawn-up 
appearance. The eruption is usually profuse. All regions 
are affected. Severe itching and sometimes burning lasts 
until the vesicles are broken, which may not be for several 
days. Sometimes there is a good deal of constitutional dis- 
turbance. This is Fox's hydroa herpetiforme. 

Dermatitis herpetiformis bullosa. In this form we have 
more or less typical bulla? filled with cloudy or serous fluid, 
from pea- to cherry-sized, irregular or angular in outline, 
and with or without an inflammatory base. They occur in 
groups, with red and puckered skin between, and more or 
less vesicles and pustules disseminated over the skin. All 
parts of the body are affected. They come out in crops at 
intervals, rupture in two or three days, and crust over. 
This is Fox's hydroa bulleux. 

Dermatitis herpetiformis pustulosa. This form is less 
clearly defined than the vesicular form, because vesicles, 
vesico pustules, and bullae often occur at the same time. 
The pustules are acuminated, round or flat, tense or flaccid, 
and vary in size from a pin-point to a twenty-five cent 
piece. The large pustules generally have an areola. They 
tend to flatten, spread, and dry in the centre, and to group. 
On the trunk we may find a central pustule surrounded by 
a variable number of small pustules. They are opaque, and 
whitish or yellowish. There may be slight hemorrhagic 
exudation into them. They are slow of development, an 
attack lasting from two to four weeks. There is more 
marked constitutional disturbance than in the other forms. 
It is accompanied by heat, pricking, and itching. It some- 
times precedes, follows, or alternates with the other forms. 

Dermatitis herpetiformis papulosa. This is the rarest 
variety of all, and consists in small or large, irregularly 
shaped, firm, reddish or violaceous papules in disseminated 
groups, the papules being usually excoriated on account of 
the scratching to relieve the severe itching. Ill-defined 
papulo-vesicles are also present. 

Dermatitis herpetiformis multiforme is simply a com- 



142 DISEASES OF THE SKIN". 

bination of all the former varieties, with the type changing 
from time to time. 

Etiology. The disease occurs in both sexes, and is sup- 
posed to be a tropho -neurosis. Little is known as to its 
causes. It occurs quite independently of pregnancy, and in 
one case became better during the same. Another case was 
aggravated during pregnancy and by irregular menstrua- 
tion. One case seemed to arise from a nervous shock. By 
Bazin the gouty diathesis was considered to be a predis- 
posing cause of hydroa, and hence possibly of dermatitis 
herpetiformis. It is probable that future investigations will 
throw some light on the origin of this disease. 

Diagnosis. The disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It differs 
from erythema multiforme by not occurring markedly upon 
the backs of the hands, wrists, forearms, and feet ; by its 
more intense itching, instead of the burning of erythema ; 
by its chronicity and greater tendency to relapse ; and by 
its obstinacy to treatment. If the case is watched for a 
time, the character of the eruption will be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture ; in 
the grouping of these vesicles in small clusters ; in its her- 
petic character; more intense itching; greater constitutional 
disturbance ; and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules ; their 
strong disposition to group; their slow evolution; their 
appearance in crops with free intervals ; the chronicity of 
its course; and obstinacy to treatment. 

It differs from herpes iris by being a general eruption, 
and by not having the groups of vesicles arranged in circles 
about a central vesicle. 

It differs from pemphigus by the grouping of its lesions, 
by their more inflammatory, herpetic aspect, and by the 
occurrence of vesicles and pustules at the same time with 
the bullae. If only bullae are present, the diagnosis is 
difficult. 



DERMATITIS HERPETIFORMIS. 143 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bullae. It de- 
velops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is a 
grave disease, often ending fatally. 

A well-marked case of dermatitis herpetiformis with 
erythematous patches, grouped vesicles, pustules, and bullae 
of stellate form, intensely pruritic and with a myriad of 
excoriations, is so characteristic as to admit of no doubt in 
diagnosis. 

Pathology. But little has yet been done in the study 
of the pathology of dermatitis herpetiformis, but we have a 
careful study of herpetiform hydroa by Elliott, 1 which is 
considered by Duhring as one variety of the disease under 
consideration. He shows that the vesicles originate in the 
epithelium of the sweat ducts, several being implicated at 
the same time, and that the ordinary signs of inflammation 
are present. He believes that the inflammation is second- 
ary, and is seated in the papillary layer of the corium. 
Degenerated nerve fibres are found, and the disease is be- 
lieved to be due to trophic nerve disturbance. 

Treatment. This disease is one of the most rebellious 
to treatment. Hygienic measures, fresh air, proper and 
restricte 1 diet, abstinence from all alcoholics, and relief 
from all nervous disturbances must be secured as far as may 
be. Nerve tonics may be given, such as arsenic, strych- 
nine, cod-liver oil, hypophosphites, and quinine ; alkaline 
diuretics, belladonna in full doses, laxatives, all may be 
tried. Duhring 2 places little faith in any of them. Locally, 
Duhring has found the best treatment to be sulphur oint- 
ment containing two drachms of sulphur to the ounce, having 
it well rubbed in with vigorous friction as in scabies. The 
frictions should be continued for an hour at a time. This 
plan is not suitable for the erythematous variety. In one 
marked case this treatment gave most satisfactory results in 
my hands. Other authorities recommend alkaline and bran 

1 N. Y. Med. Journ., 1887, xlv. 449. 

2 Trans. Amer. Derm, Assoc., Xew York, 1890. 



144 DISEASES OF THE SKIN. 

baths, dusting on starch powder with zinc, Lassar's paste, 
resorcin ointment, liquor carbonis detergens in water, 5\j to 
Sviij ; calamine lotion, liquor picis alkalinus, tar ointment, 
solutions of carbolic acid, 5j to 5j, dabbed on. All these 
will afford a certain measure of relief, but the disease is apt 
to laugh at our efforts to drive it out. 

Prognosis. The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to re- 
lapse. The course of the disease is essentially chronic ; it 
may last for many years ; it shows a strong tendency to re- 
lapse at longer or shorter intervals ; and, as a rule, does not 
materially affect the patient's health. 

Dermatitis, Malignant Papillary. See Paget's Disease 
of the Nipples. 

Dermatitis Medicamentosa. By this is meant inflamma- 
tion of the skin due to the ingestion of drugs or to their 
absorption. There are a great number of drugs that may 
cause eruptions upon the skin in susceptible individuals. 
These effects are seen but rarely with some drugs, and quite 
constantly with others. The modus operandi of drugs in 
producing eruptions is probably not the same in all cases. 
Some, doubtless, act by irritating the skin while circulating 
in the blood ; some while being excreted by the glandular 
apparatus ; while most of them do so by direct or reflex 
excitation of the vasomotor nerves. Idiosyncrasy is marked 
in all of them. Erythema is the principal feature of nearly 
all drug eruptions, to which may be added vesiculation or 
pustulation. Two drugs, bromine and iodine, produce pus- 
tular eruptions in nearly all cases where ingested. All 
drug eruptions appear with more or less suddenness, and 
disappear quite promptly when the drug is stopped. They 
are symmetrical and general in distribution as a rule. They 
may be universal or localized. The cause of all doubtful 
eruptions of an erythematous type should always be sought 
for in the ingestion of some drug. As a rule, little if any 
treatment is required for this form of dermatitis apart from 
stopping the drug. Sometimes the system becomes accus- 
tomed to a drug, and after a time does not react unfavorably 



DERMATITIS MEDICAMENTOSA. 145 

to it if its administration is persisted in. With most drugs 
this is not the case. 

Dr. P. A. Morrow 1 has written an excellent work on the 
subject of drug eruptions, and, with the author's kind permis- 
sion, upon this I have largely drawn in the preparation of 
this section. To it the reader is referred for fuller informa- 
tion on the subject. Here no more than a skeleton account 
can be given. 

Acids : Benzoic acid may produce an eruption of urti- 
caria, maculo-papules, or erythema. Boric acid may cause 
an erythematous, psoriatic, or erythemato-bullous erup- 
tion. The psoriatic form is unique. Carbolic acid causes 
an erythema that may be scarlatinous in character, Nitric 
acid, in rare cases, gives rise to a pustular eruption. Sali- 
cylic acid produces erythematous, urticarial, vesicular, bul- 
lous, petechial, or purpuric manifestations. Tannic acid 
caused an erythema in one case. 

Aconite gives rise to itching, vesicular, pustular, or bul- 
lous lesions. 

Amygdala amara causes erythema. 

Antimony causes an urticarial or vesiculo-pustular erup- 
tion. 

Antipyrin gives rise to an erythema, consisting of small, 
irregularly circular, slightly elevated patches, which may be 
discrete or confluent, and is at times followed by desquama- 
tion Profuse sweating and itching may accompany it, and 
it affects the chest, abdomen, back, and extremities, specially 
their extensor surfaces. It may be measly in character or 
purpuric. It has also given rise to a bullous eruption. 

Arsenic causes erythema of scarlatina type, papules, pete- 
chise, urticaria, vesicles, pustules, and an erysipelatous 
eruption. Itching may attend some of these eruptions, and 
grayish or brownish discolorations of the skin have followed 
prolonged ingestion of the drug. 

Belladonna produces a scarlatinal eruption with or with- 
out vesicles and pruritus. As the fauces are often reddened 
the resemblance to scarlatina is striking. It will clear up 

1 Drug Eruptions. Win. Wood & Co., Xew York, 1887. 

7 



146 DISEASES OF THE SKIN". 

in twenty-four hours, and the eruption is patchy, not punc- 
tate. Moreover, there are none of the prodroma of scarla- 
tina, nor the strawberry tongue. The pupils may be 
dilated. 

Bromine, in combination with potassium, ammonium, and 
other salts, produces the well-known "bromic acne" so 
commonly seen in the treatment of epilepsy. It is an out- 
break of dark-red inflammatory papules, papulo-pustules, 
and cutaneous abscesses that bear a close resemblance to 
acne, and, like it, often leave scars. It differs from acne in 
having a predilection for hairy parts, a wider distribution, 
and in occurring at all ages. This is the most common 
form of bromine eruption, but erythematous, urticarial, 
papular, ulcerative, verrucose, vesicular, and bullous erup- 
tions have been met with. It would be desirable to prevent 
these eruptions, but thus far there is nothing that will do so 
with certainty but stopping the administration of the drug. 
Arsenic, or sulphide of calcium, or aromatic spirits of 
ammonia may be tried. 

Calx sulphurata gives rise to vesicles, pustules, and 
furuncles ; rarely to petechia. 

Cannabis indica caused a vesicular eruption in one case. 

Cantharides and capsicum give rise to erythematous and 
papular lesions. 

Chloral produces erythematous, papular, urticarial, vesic- 
ular, and petechial eruptions. 

Cinchona and quinine produce all the primary lesions of 
the skin, though most frequently an erythema of scarlatina 
type, attended by congestion of the fauces and followed by 
desquamation. 

Conium has an erysipelatous eruption as well as an 
erythematous one. 

Copaiba and cubebs. Their most common eruption is an 
erythema which is often of a scarlatina type, but may 
resemble measles, and may be followed by desquamation. 
Outbreaks of urticaria, vesicles, bullae, or petechia may 
occur. Pruritus may be present. The odor of the drug 
may usually be detected in the breath. 



DEKMATITIS MEDICAMENTOSA. 147 

Digitalis produces an erythema of an erysipelatous, papu- 
lar, or urticarial character. 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechiae. 

Ferrum is said to produce an acne. 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 

Hyoscyamus produces an itching erythematous eruption, 
with more or less oedema and wheals. Purpura has also 
followed its use. 

Iodine and its compounds, like bromine, gives rise to a 
upon the face, back, and upper part of the chest and arms, 
but pustular or papulo-pustular, acneiform eruption, usually 
often general. This is the most typical form of eruption, 
but an erythema limited to the face and chest, or general, 
an urticaria, a vesicular erythema or an eczema-like erup- 
tion, a bullous form resembling pemphigus, as well as car- 
buncular, petechial, and nodular eruptions, may occur. 
Sometimes there will be more than one type present. It is 
supposed that iodic eruptions occur more often in cases in 
which the kidneys are more or less inactive. They some- 
times follow the administration of very small doses. It is 
thought that the iodide of sodium is less apt to cause cuta- 
neous disturbances than are the other salts of iodine. At 
times the system becomes accustomed to the drug, or the 
kidneys acting more freely relieve the skin. The trouble 
may be relieved or, to a large extent, obviated by administer- 
ing the salt largely diluted in vichy or seltzer water, or giving 
it in milk. The free use of alkaline diuretics will relieve 
the skin. Arsenic has also been commended, but does no 
better here than in the bromine eruptions. 

Ipecac in one case caused burning heat with an erysipe- 
latous eruption. 

Nux vomica and strychnine have given rise to a scarlatina- 
like erythema and a miliary eruption. 

Oleum morrhuae may cause an eczematous eruption or an 
acne. 

Opium causes itching and an erythema resembling scar- 



148 



DISEASES OF THE SKIN. 



latina or measles in character, which, though often widely 
distributed, is not infrequently limited to certain regions. 

Morphine may cause urticaria, ulcers, a papular, vesicular, 
or pustular eruption. 

Phosphorus causes bullous eruptions, and also purpura. 

Pix liquida produces an erythema. 

Potassii chloras, in two instances, has caused a papular 
erythema. 

Santoninum produces an urticaria or a vesicular eruption. 

Stramonium gives rise to an itching or burning scarlat- 
inoid erythema, a petechial eruption, or an erysipelatoid 
inflammation. 

Sulphonal produces a scarlatiniform erythema. 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tansy has caused a varioliform eruption. 

Veratria gives rise to an erythematous eruption. 

Dermatitis Papillaris Capillitii. Synonyms : Dermatitis 
papillomatosa capillitii ; Framboesia ; Sycosis framboesia 
(Hebra) ; Sycosis capillitii (Rayer) ; Mycosis framboesiodes, 
or Acne keloidique, or Pian ruboide (Alibert) ; Acne keloid. 

Fig. 15. 




Symptoms. This is one of the rare diseases of the skin. 
It begins as an eruption of small-sized papules upon the 
back of the neck at the margin of the hair. They are of 



DERMATOLYSIS. 149 

the color of the skin, or slightly red with an inflammatory 
halo ; exceedingly hard and firm ; and when pricked they 
give vent to a little bloody serous fluid. Increasing slowly 
in number and crowding together they form raspberry-like 
elevations with uneven lobulated surfaces. Gradually, the 
disease spreads laterally and also upward upon the hairy 
scalp, even reaching the vertex after months and years. 
After a time the masses may soften a little and contain pus. 
At times they secrete a foul-smelling fluid, and crust. Gradu- 
ally they become sclerosed and keloidal. Pustules may 
form on the hairy scalp, and little tufts of hair protrude out 
of them. When they become keloidal they may be bald or 
tufted with hair. Hairs plucked from the growths are some- 
times normal, and sometimes atrophied. There may be 
pain or tenderness, or there may be no subjective symptoms. 

Etiology. Both men and women are affected, and the 
disease may begin at any age. The etiology is obscure. It 
has been suggested that they may be due to the rubbing of the 
shirt collar. 

Diagnosis. If the charateristics of the disease are re- 
membered there should be no difficulty in diagnosis. In 
sycosis we have no hard tumors, and the single hairs are 
surrounded by pustules. Warts are not so hard, do not 
tend to increase in size, and do not become keloidal. 

Treatment. The best treatment is to scrape away the 
small ones with the curette and excise the larger ones. 
After either operation the base must be cauterized. They 
may be removed with the galvano-cautery. 

Prognosis. So far as reported the growths are benign, 
and have no effect upon the health of the patient. They 
are progressive, and show no tendency to spontaneous re- 
covery. They are obstinate to treatment and prone to 
relapse. 

Dermatolysis (Du 5 rm-a 2 t-oW-si 2 s). Synonyms: Chalasto- 
dermia ; Cutis pendula ; Pachydermatocele. 

This term is applied to two entirely different diseases of 
the skin. In one we have folds of loose thickened skin and 
subcutaneous tissue that sometimes form huge masses hang- 



150 DISEASES OF THE SKIN". 

ing down from the side of the face, trunk, or any part of 
the body. The skin is soft and does not appear altered, ex- 
cepting that it is pigmented to a certain extent. This form 
is really a species of fibroma. True dermatolysis is a yet 
more rare affection, in which, owing to some defect in the 
attachments of the skin, it can be pulled away from the 
body like the skin of a cat. The " Elastic-skin Man " is an 
instance of this. There have been several of these freaks. 
The one mentioned could pull the skin from his chest up to 
his eyes. The condition is congenital, but can be increased 
by cultivation. 

Treatment. The treatment of the first variety is by 
excision before it becomes too large. 

Dermatomycosis. A disease of the skin due to a vege- 
table parasite. 

Dermatosclerosis. See Scleroderma. 

Dermatosis Kaposi. See Atrophoderma pigmentosum. 

Desquamative Scarlatiniform Erythema. See Dermatitis 
exfoliativa. 

Diabetide (De-a 3 -ba-ted) is a French term for a local 
lesion occurring as a manifestation of diabetes mellitus. Ac- 
cording to Brocq they may be divided into two great classes : 
1. Those in direct relation to alterations in the general 
economy, such as pruritus, chronic papular urticaria, acne 
cachecticorum, erythema, lichen, eczema, herpes ecthyma, 
furuncle, carbuncle, xanthelasma, gangrene. 2. Derma- 
toses due directly to the contact of the secretions of the 
body charged with sugar, and more especially the eczema of 
the genitals, caused by contact with the urine. 

Kaposi 1 has described a bullo-serpiginous gangrene of dia- 
betics, which begins by a disseminated eruption of bullae upon 
the extremities. The bullae dry up in the centre into a black 
crust, while at the periphery there is a ring of fluid pushing 
up the epidermis. When the crust is removed sphacelated 
skin is exposed, which separates and leaves a red, granu- 

1 Wien. med. Presse, 1883. 



ECTHYMA. 151 

lating surface. The penis is a favorite site for this form of 
gangrene. It must be treated on general surgical principles. 

Distichiasis (Di 2 s-ti 2 k-i 2 -a'si 2 s.) This is a congenital or 
acquired condition of the cilia, in which they grow in two 
distinct rows, the inner row being directed inward so as to 
scrape the cornea. According to Michel, generally the 
outer third of the upper lid is affected alone, the deformity 
is symmetrical and bilateral, and of embryonic origin. Elec- 
trolysis offers the best method of relief. These cases belong 
to the ophthalmic surgeon. 

Dracontiasis. See Guinea-worm disease. 

Durillon. See Callositas. 

Dysidrosis. See Pompholyx. 

Ecchymomata and Ecchymoses. See Purpura. 

Ecdermoptosis (Huguier). See Molluscum epitheliale. 

Ecthyma (E^-thi'ma 3 ). Synonyms : Furunculi atonici*; 
Phlyzacia agria : (Ger.) Eiterpusteln ; (Fr.) Furoncles aton- 
iques ; (Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with hard, 
elevated, reddened bases, attended by the formation of thick, 
greenish, or dark-colored crusts, and followed either by cica- 
trices or dark pigmented spots. 

Symptoms. Though the existence of this disease as a 
separate entity is denied by many authorities, and relegated 
to the domain of eczema, it presents certain well-defined 
symptoms that entitle it to be regarded as a distinct disease. 
It consists in the outbreak of one or more round, flat pus- 
tules, whose covers are not fully distended, and which have 
an inflammatory areola. In size they vary from a split-pea 
to a finger-nail, or larger. At first they are white or yellow. 
Subsequently they may or may not become reddish from 
the admixture of blood. They may dry up, forming a 
crust which, on falling, leaves a healthy surface. Or they 
may rupture spontaneously or be broken, and form a thick, 
greenish or blackish crust, under which is a raw or super- 
ficially ulcerated surface, which on healing leaves a pig- 
mented or slightly cicatricial spot. In subjects in bad 



152 DISEASES OF THE SKIN. 

hygienic surroundings quite deep ulcers may result. These 
pustules are usually discrete, but they may group. They 
are both painful and tender. Any part of the body may 
"be affected, but they are most often seen on the ex- 
tremities, especially the legs where the hair is coarse, the 
shoulders, and the back. The course of the disease may 
be acute, each pustule lasting five or ten days, and the 
whole disease lasting about two weeks, but generally it is 
chronic and kept up by the outbreak of fresh crops. There 
is more or less itching. It is not contagious, but it is auto- 
inoculable. Febrile symptoms may accompany or precede 
the outbreak of the disease, but as a rule they are absent. 

Etiology. Dirt, want, bad hygienic surroundings, the 
strumous diathesis, or a broken-down cachectic condition 
brought on by intemperance or dissipation, all predispose 
to the disease. It is quite often seen in the genus " tramp/' 
Crocker believes that it is but a form of impetigo contagiosa. 
It follows, not infrequently, upon scratching on account of 
pediculi and scabies. It is most often seen in adults, and 
is rare in children. Like in all other purulent diseases, pus 
cocci are found in the pus, and are regarded by many as the 
cause of the disease. 

Diagnosis. Ecthyma differs from eczema in having much 
larger pustules, which are discrete and not confluent, in the 
marked areola about the pustules, and in the absence of all 
other signs of eczema. It differs from impetigo contagiosa in 
its pustules being deeper ; in their location upon the extremi- 
ties rather than upon the face and hands ; in not having 
that flabby, bullous look of a burn of the second degree, so 
common to impetigo ; in having thick greenish or blackish 
crusts, and not straw-colored stuck-on crusts ; in occurring 
in more or less debilitated adults and not in otherwise 
healthy children, and in being non-contagious. From im- 
petigo it differs principally in its being a deeper and more 
inflammatory process, and in occurring in debilitated subjects. 
It resembles the large, flat, pustular syphiloderm, but its 
crusts are not heaped up into oyster-shell-like masses, as in 
syphilis, and when they are removed they leave a more super- 
ficial, and not so punched-out an ulcer. There is more pain 



ECZEMA. 153 

and itching in ecthyma, and an entire absence of other 
symptoms or history of syphilis. 

Treatment. The first thing to be done in these cases 
is to obtain cleanliness, proper hygienic surroundings, and 
complete abstinence from alcoholics. If there is general 
debility tonics must be given and the dietary improved. 
Locally, all crusts must be removed with soap and water, 
the lesions dressed with an ointment containing some anti 
septic such as — 

R . Hydrarg. ammon., J)j ; 5|5 

Ungt. zinci oxidi, Jj ; 301 M. 

and the part enveloped in a rubber bandage, where such is 
applicable. An ointment or oil containing five or ten 
grains of salicylic acid to the ounce will also answer well. 
If ulcerations have formed they should be treated as will be 
indicated under Ulcer. 

Eczema (E^'-zeWa 3 ). Synonyms : (Fr.) Dartre vive, 
ouhumide, eczema; (Ger.) Ekzem, Hitzblatterchen, Flechte, 
nassende Flechte, Salzfluss ; Salt rheum, Tetter, Humid 
tetter, Scall, Scald, Heat eruption. 

A non-contagious, inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with itching, 
desquamation or loss of the cuticle, and usually with the 
exudation of serous or sero-purulent fluid either beneath 
the cuticle or upon the denuded surfaces. It may present 
erythema, papules, vesicles, or pustules, and its lesions 
show a decided disposition to run together and form in- 
filtrated patches. 

Symptoms. This is a most protean disease. It has been 
well said that if a student learns to recognize and treat 
syphilis and eczema, he has possession of the key to the 
whole of dermatology. There are six prominent symptoms 
of the disease : 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusting or scaling. 

7* 



154 DISEASES OF THE SKIN. 

6. Cracking of the skin. 

In every case there will be four or five of these symptoms; 
or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and malaise 
be present they are accidental, or an expression of that 
condition of the system that predisposes to the disease, and 
not part of the disease itself. Very often the first thing 
that attracts the patient's attention is itching, and when he 
examines the skin he finds it reddened and either scaly, or 
covered with papules, vesicles, or pustules, or moist. 

The tendency of eczema in all forms is to form patches, 
and these are infiltrated to greater or less extent ; ill de- 
fined ; shade off imperceptibly into the surrounding skin so 
that it is hard to say. where they end, and with outlying 
lesions about the patches ; irregular in shape ; of all sizes, 
sometimes involving nearly the whole cutaneous surface; 
sometimes swollen ; and of dark-red color, sometimes with a 
shade of yellow. Beginning by a few lesions the disease 
increases more or less rapidly in extent. It may clear away 
after a short time, or it may last weeks or months, or be- 
come chronic, showing little tendency to recovery. There 
is no constant rule as to the course of the disease, though 
many cases occur and recur at certain seasons of the year ; 
it may be in the summer, spring, autumn, or winter. Any 
or all parts of the skin may be affected, but it has a pre- 
dilection for the flexures of the joints, the face, the scalp, 
and the sulcus behind the ear. There may be but a single 
patch or many of them. It commonly affects both sides of 
the body, but with no marked symmetry. 

The subjective symptoms are itching, burning, and a 
feeling of heat and tension. Of these, the most constant is 
itching, which is present in all cases and is often so great as 
to cause the patient to excoriate the skin by scratching. 
It is subject to exacerbations and remissions. The latter 
may be complete or incomplete. Burning and tension are ex- 
perienced for the most part only at the beginning of the attack 
or during some exacerbation of a subacute or chronic case. 

The old definition of the disease was that it is a vesicular 



ECZEMA. 155 

one. It is well to disabuse the mind of this impression at 
the start, as there is a form of the disease that is dry 
throughout : the erythematous form. There are five vari- 
eties of eczema, known as the erythematous, papular, vesic- 
ular, pustular, and squamous. Eczema madidans is but a 
convenient term to describe a very moist eczema. Eczema 
rimosum or rhagadiforme is but an eczema in which the 
skin cracks about the joints. Unna has recently introduced 
the term eczema seborrhoicum, which, though it has not yet 
taken a secure place in the family, has won so much notice 
that it merits a special description. 

Before discussing each of these varieties by itself, it is 
necessary to understand that no one of them, excepting 
perhaps eczema erythematosum, is clear-cut and unchang- 
ing. On the contrary, the disease may begin as a papular 
erythema; upon the papules vesicles may form which will 
run together and soon break down of themselves and form 
a weeping patch ; the subsequent lesions may then be pus- 
tules, and the final stage through which all varieties pass 
before recovery is the squamous. Now we are ready to 
study each variety by itself. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and in 
children. Beginning as one or more ill-defined red patches, 
it soon forms a continuous patch by the coalescence of the 
smaller ones. Sometimes the whole face is involved, sometimes 
there are several patches. The inflammation is often attended 
by oedema to such an extent that the eyes are nearly closed 
if the disease is in their neighborhood. The patient experi- 
ences great discomfort on account of the burning and stiffness 
of the skin. The skin feels harsh, dry, and thickened; it is 
swollen ; its color is bright or dull-red ; and there is a slight 
amount of small adherent scales. If it occurs on contiguous 
folds of skin there may be moisture. Upon the face vesicles 
may develop, but this is exceptional. After lasting for a 
time the symptoms may subside, and recovery takes place, 
the patches fading away altogether and not in the centre. 
It may assume a chronic form and last for years. 

Eczema papulosum. This is the lichen simplex of the 



156 DISEASES OF THE SKIN. 

old writers. It consists in an eruption of pin-point to 
pin-head, bright or dull-red, acuminate, discrete, grouped, or 
perhaps confluent papules. Very frequently the papules 
are capped by vesicles. The papules may remain discrete 
throughout their course with an occasional small confluent 
patch to betray the nature of the disease. This is one of 
the most itchy varieties of this pruriginous disease, and the 
scratching consequent upon it produces excoriations, and 
breaking down the vesicles and papules gives exit to the 
serum and converts the patch into a moist one. This 
variety is located preferably on the extensor aspects of the 
limbs. The life of the individual papule is comparatively 
long — days or weeks. It is often obstinate to treatment. 

Eczema vesiculosum is the most common and most char- 
acteristic variety, and consists in an eruption of pin-point 
to pin-head, rounded or acuminate vesicles that appear upon 
a reddened surface in immense numbers. Prickling and 
tingling precede the outbreak ; intense itching, and more or 
less swelling attend it. The vesicles group, and perhaps 
coalesce, and soon rupture of themselves, and discharge a 
clear, sticky, mucilaginous fluid that possesses the quality 
of stiffening and staining linen, and dries into a light-yel- 
lowish crust. The vesicles rupture so early that it is rare 
for the physician to see a case with the vesicles intact. 
New vesicles form about the patch, and break down ; the 
discharge continues from the sites of the vesicles, and the 
crust continuously forms A raw surface is exposed when 
the crusts are removed. Sometimes, on account of the crust 
being prevented from forming on account of friction, there 
is a weeping surface which has been called eczema madidans 
or rubrum. Eventually the discharge ceases, the hypergemia 
lessens, scaling takes place, and after a time the skin re- 
turns to its normal condition. This variety of eczema seeks 
the soft parts of the skin, the flexures of the joints, the 
flexor surfaces of the limbs, and behind the ears. It may 
involve the whole or nearly the whole cutaneous surface. 
After it has lasted a little while in a part, the skin is evi- 
dently thickened. With it papules and pustules very gen- 
erally are found. 



ECZEMA. 157 

Eczema pustulosum. Under this head many authors, 
notably the Vienna school, place all cases of impetigo. 
Like the pustular syphilide, this variety of eczema occurs 
in more or less broken-down, cachectic, delicate, or strumous 
subjects. It is the most common form of eczema met with 
in children, and in them occurs by preference on the face 
and head. The eruption consists of small pustules that 
may start as pustules or develop from vesicles. They are 
present in large numbers, and tend to break down and form 
patches covered with greenish crusts. If blood is drawn 
by scratching, the crust will be blackish. They are some- 
what larger than the characteristic vesicles, and have a 
fondness for hairy parts, though any part of the body may 
be affected. This and the previous variety often merge into 
each other. It is not so itchy as the other forms. It may 
change into an eczema madidans, and it passes through the 
squamous stage on the way to recovery. 

Eczema squamosum is the final stage through which 
most cases pass on their way to recovery. In it the skin is 
dry, red, and covered with thin, papery, flat, large or small 
scales. It is a condition of the skin in which the formation 
of its corneous layer falls short of perfection. The disease 
may continue in this condition for an indefinite time, a 
chronic eczema, with occasional exacerbations. Then it 
may pass away entirely and the skin become quite well ; 
or some local injury may cause an acute outbreak of eczema. 
The skin in this variety is more or less thickened, and deep 
cracks are liable to form about the joints, because the infil- 
tration of the skin interferes with its elasticity, and it breaks 
instead of stretching. While the patches are usually ill 
defined, in some cases they will be round and with well- 
marked borders. 

Eczema may be acute or chronic — terms that apply not 
to the length of time that the disease has lasted, but to the 
symptoms it presents. It predisposes to ulceration upon 
the legs when combined with varicose veins, and then is 
named eczema varicosum. This must not be confounded 
with a somewhat similarly sounding name, eczema verru- 
cosum, which is a rare variety, in which the skin takes on 



158 DISEASES OF THE SKIN. 

a warty appearance on account of a hypertrophy of the 
papillae. 

Etiology. Like its symptoms, its causes are numerous. 
It may arise from purely local causes, but even then it is 
probable that we should assume, in most cases, a predispo- 
sition on the part of the skin. Thus, we have eczemas of 
the hands in washerwomen. Perhaps for a score of years 
they had washed in the same water and with the same soap 
without eczema. Then under the same local conditions, but 
with some unknown internal constitutional state, an eczema 
breaks out. Of external irritants we have the sun, water, 
intense artificial heat, acids, alkalies, traumatism, rubbing 
of opposed surfaces or chafing by the clothing, parasites; 
in fact, just the same things as will cause a dermatitis, only 
now the action goes further, and a catarrhal condition of 
the skin results. Cold has an undoubted influence on the 
skin, and eczema is more common in winter than in summer, 
and is generally aggravated by extremely low temperature, 
even when the patient keeps in the house. It has been 
observed that children with eczema grow worse when it is 
cold and a high wind is blowing, even though they are not 
exposed directly to these conditions. Vaccination may act 
as a local cause. 

Of the internal or predisposing causes, perhaps the most 
common and active is some digestive or intestinal disturb- 
ance — it may be dyspepsia or mal-assimilation, or derange- 
ment of the liver, or constipation. At other times the 
kidneys are at fault. Diabetes and Bright's disease both 
predispose to eczema. Chlorosis and anaemia, uterine dis- 
orders and the menopause, and the strumous diathesis, are 
at times active factors. Derangements of the nervous system 
are exciting causes ; now and again we will meet with cases 
which appear suddenly after some nervous shock. Rheuma- 
tism and gout and varicose veins are other predisposing 
causes. To most of these internal causes some external cause 
must be added before the eczema appears. 

The French school of dermatology has long held to its 
theory of diathesis, and has taught that the dartrous dia- 
thesis is the cause of eczema. Outside of France little is 






ECZEMA. 159 

known about diathesis. A vulnerability of the skin is 
necessary for the production of an eczema, and many 
patients may fairly be regarded as eczematous, just as others 
may be spoken of as gouty or rheumatic or psoriatic. This 
peculiarity or tendency of the skin may be inherited, and 
in so far eczema may be regarded as hereditary. 

The disease attacks all ages, conditions, races, and both 
sexes, and is the dermatosis we are most often called upon 
to treat. It is especially common in children. In Bulk- 
ley's tables, out of 3000 cases, 676 occurred under five 
years of age, and of these 520 were in children under three 
years. Of the remaining cases 1234 were between the ages 
of twenty and fifty, and were divided about equally in each 
decade. About one-third of all skin diseases are eczema. 

These many etiological factors indicate that it is probable 
that our present eczema is a too composite disease, and it is 
for this reason that attempts are constantly made to take 
away certain members of the family and form them into 
separate diseases. Unna and others have asserted of late 
that a parasite, yet undiscovered, is the cause of one variety 
of eczema, his Eczema seborrhoicum. Unna further teaches 
that there are two other varieties of the disease, one due to 
reflex nervous irritation, such as is seen during dentition of 
infants, and one dependent upon the tubercular diathesis. 

Pathology. Eczema is a catarrhal inflammation of the 
skin, analogous to that of the mucous membrane, which has 
its seat principally in the papillary layer of the skin and in 
the rete. This superficial location of the disease is the 
reason why the skin is left unmarked after the disease has 
been recovered from. Atropho-neurosis is supposed by many 
to be the cause of the disease when not due to local irri- 
tants, and Crocker quotes Marcacci as having found 
changes in the sympathetic in a fatal case of universal 
eczema. 

Diagnosis. If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, they will be of great aid in diagnosis. 
To them should be added the tendency the disease evinces 



160 DISEASES OF THE SKIN. 

to locate in the folds of the joints, between apposed surfaces 
of skin and behind the ears, and the peculiar mucilaginous 
quality of the exudate, which stiffens and stains linen and 
glues the hair together. Fortunately, a diagnosis of eczema 
will fit one out of every three cases. Here will be given 
the general diagnosis, reserving for the sections on regional 
eczema the diagnosis of special forms where necessary. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently runs over into it. As a rule, it runs 
a more rapid course, its vesicles are longer preserved, bullae 
are apt to form, there is burning rather than itching, and it 
heals readily on removal of the cause. 

Dermatitis exfoliativa is, when fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is also 
dry, and has abundant large scales, while eczema will ex- 
hibit moisture somewhere, and does not scale so abundantly. 
For further points in diagnosis, see under Dermatitis ex- 
foliativa. 

Erysipelas is attended by fever and marked constitutional 
disturbances, has a sharply defined border, advances steadily 
at its margin, and forms a swollen, deep-red patch upon 
which large vesicles and bullae form. The margin of eczema 
is ill-defined, fading off into the surrounding skin ; its vesi- 
cles are pin-point to pin-head size, and there is little or no 
constitutional disturbance. Eczema has a dry, rough sur- 
face in the erythematous form, while erysipelas has at first 
a smooth and shining one. 

Erythema burns rather than itches ; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. It lacks 
the itching, exudation, scaling or crusting, and cracking of 
eczema, and is prone to appear upon the backs of the hands 
and wrists, and is symmetrical. 

Herpes febr His resembles eczema only in having vesicles 
upon a red surface. It occurs usually in a single patch 
upon the face ; its vesicles are discrete, and show no ten- 
dency to run together ; its course is short, and it pains or 
burns, but does not itch. 

Zoster occurs in the form of a number of herpetic patches 



ECZEMA. 161 

following the course of a nerve, and occupying only one side 
of the body — symptoms that are entirely foreign to eczema. 

Impetigo contagiosa occurs for the most part upon the 
face, hands, and exposed parts. Its pustules are large, flat, 
and discrete, not small and conglomerate. Its crusts are 
thin and stuck on, not greenish and thick, as in eczema. It 
is a vesico-pustular disease, and often presents large vesicles 
or bullae that look like burns of the second degree. 

Lichen ruber and Pemphigus foliaceus do bear some 
resemblance to eczema erythematosum when generalized. 
But the history of these two is quite different from that of 
eczema. 

Phthiriasis or pediculosis shows parallel scratch-marks 
over the shoulders and excoriations about the waist and on 
the limbs where the seams of the clothing come. If on the 
head, the lesions will be on the occiput, and nits will be 
found on the hair of that region, or of the temples. The 
eruption to which they give rise is an eczema, but the cause 
of it is evident. 

Pruritus cutaneous has no lesions, properly speaking, 
and the excoriations met with are not in patches, but scat- 
tered all over the body at intervals and irregularly. The 
itching is more paroxysmal than it is in eczema, and the 
itching is the only symptom that it has in common with 
eczema. 

Psoriasis, when occurring in typical round or oval 
sharply defined patches, with silvery scales, offers no diffi- 
culty in diagnosis from a typical eczema. From circum- 
scribed eczema, that occurs occasionally, it may be diag- 
nosticated by the color — of a brighter red ; by the scaling, 
that is whiter, thicker, and more laminated, and by finding 
characteristic patches either of the one or the other disease 
elsewhere on the body. When psoriasis occurs in large areas 
it is diagnosticated from squamous eczema by its sharply 
defined border ; its marginate form ; its brighter red ; its 
more abundant, thicker and whiter scales ; its fondness for 
the extensor surfaces of the limbs, while eczema seeks the 
flexor aspects and the flexures of the joints ; its uniform 
character and constant dryness, against the polymorphous 



162 DISEASES OF THE SKIN. 

character of eczema and its moisture ; and its history of fre- 
quent relapses, always of the same sort and always on the 
elbows and knees. 

Rosacea occupies the middle third of the face from above 
downward, attacking the forehead, nose, and chin, while 
eczema affects the whole or part of the face, but never occurs 
on these limited regions alone ; it burns rather than itches; 
it shows telangiectases, and its redness and occasional dis- 
crete, sluggish, superficial pustules are very different from 
either the dry, harsh, scaly redness of an erythematous 
eczema, or the crusted surface of a pustular eczema. 

Scabies may be diagnosed from eczema by its location 
upon the anterior surface of the wrists, between the fingers, 
and upon the abdomen and buttocks of both sexes, and 
upon the nipples and breasts of women, and the penis of 
men. In children the feet are often affected. The pres- 
ence of cuniculi is diagnostic, but they are hard to find in 
some cases. Of course, the eruption in scabies is an eczema, 
but it is important to recognize, where possible, the cause of 
an eczema in order to cure it. 

Syphilis, like eczema, is a protean disease, but it does not 
itch, and that is an important point in differential diagnosis. 
It is true that occasionally a papular syphilide does itch, but 
the occurrence is so rare that it need not here be taken into 
account. The early syphilides are general eruptions, whether 
macular, papular, or pustular, and the efflorescences never 
form patches, though they may show more or less grouping. 
When the other symptoms of syphilis are present, such as 
the initial lesion, mucous patches, and alopecia, there can 
be no difficulty. It is the later manifestations of the dis- 
ease that offer difficulties in diagnosis, and especially the 
grouped papular lesions that occur on the palms in the form 
of scaly patches. In some cases a diagnosis is impossible. 
The most suggestive symptom of syphilis is the occurrence 
of the disease upon one hand alone. The patch will have 
a wavy outline ; will be scaly, but not moist or crusted ; will 
often show healthy skin in the middle ; and there are apt to 
be isolated, scaly, dark-red papules somewhere in the neigh- 






ECZEMA. 163 

borhood. The finding of scars of old lesions, or some other 
evidence of syphilis, will aid us. 

Urticaria, when it has induced itching and been scratched, 
looks like an eczema. We recognize it by the finding of 
wheals, or the history of them, and by the isolated, scattered 
distribution of the excoriations and papules. Some cases of 
papular urticaria can only be diagnosticated after prolonged 
watching. 

Treatment. While not a few cases of eczema arise from 
purely local causes, and require only external treatment, in 
most cases the patient is not in good condition, and he needs 
treatment quite apart from his skin disease. It is well for 
us to begin our treatment of a case by regarding it as one 
of a sick man rather than of a sick skin. The better prac- 
titioner of medicine a man is, the better his chances of curing 
his case will be. It is not the part of the writer on matters 
dermatological to instruct his readers in general medicine, 
and here I can give only an outline of the treatment proper 
to be followed. 

If the patient is anaemic we should administer iron, and 
see that he has plenty of fresh air and a sufficient amount 
of exercise. If he is run down, and especially if he is of 
a strumous habit, cod-liver oil will be indicated. To the 
nervous patient, strychnine, hypophosphites, and other 
nerve tonics should be administered. The dyspeptic needs 
mineral acids, nux vomica, pepsine, or bismuth and soda, 
according to the different form the trouble takes. Those 
suffering from uterine diseases need the treatment best 
suited to their case. The gouty and rheumatic will be bene- 
fited by alkalies, such as the acetate of potash or the phos- 
phate of sodium. Colchicum will be useful in gouty cases. 
In fact, there is no specific for eczema, and each case should 
be studied and treated for itself. 

But nearly every case requires attention to the diet and 
exercise, and to the proper action of the bowels and kidneys. 
The diet is of special importance. Piffard 1 has found that 

1 Materia Medica and Therapeutics of the Skin. Wm. Wood & Co., 
N. Y., 1881. 



164 DISEASES OF THE SKIN". 

56 per cent, of his cases of eczema have been carnivorous — 
that is, eating meat three times a day and but little bread 
and vegetables; 40 per cent, omnivorous, and but 4 per 
cent, herbivorous. Many of the cases eat too much and 
exercise too little. Many suffer from distress of stomach 
after eating certain articles Some eat too little, and that 
of improper sort. The indications for treatment are there- 
fore obvious. The greatest difficulty to contend with is the 
objection most people have to dieting of any sort. 

In an acute eczema of any considerable extent it is always 
best to put the patient on a restricted and simple diet, and 
of these, where milk is well borne, a milk diet is the best. 
Some two quarts of milk may be taken during the day in 
divided doses, with dry toast or toasted crackers. After a 
few days a more liberal diet may be allowed, as in subacute 
and chronic eczema. 

In subacute and chronic eczema meat should be taken 
but once a day, and should be beef, mutton, or chicken, 
and these should be eaten in the middle of the day when 
possible. Breakfast and supper should be very simple, of 
crackers and milk, bread and milk, or some of the grains 
well cooked, and eaten without sugar. Fish may be allowed, 
but not those with dark meat or oily. An occasional egg 
may be eaten in the morning, but not every day. No pastry, 
cake, or confectionery should be allowed. Apart from abso- 
lute simplicity the patient's taste may be consulted, care 
being taken to avoid anything that he knows will disagree 
with him. It is a good rule to tell the patient that he may 
eat what he likes, but not of more than two dishes at a 
meal. It is unlikely that he will then overeat. Those who 
eat too little for any reason should be directed to take that 
little more often during the day. The dyspeptic should 
drink a cup of hot water about a half-hour before meals. 
In these cases it is sometimes necessary for a time to resort 
to kumyss or matzoon, and artificially digested foods, but 
the sooner he can return with comfort to a more natural 
diet the better. Fried and warmed-up meats should be 
avoided in all cases. Fruits fully ripe or stewed can as a 
rule be liberally partaken of. 






ECZEMA. 165 

All alcoholic drinks must be absolutely forbidden. Malt 
liquors are specially obnoxious to all irritable skins. Tea, 
coffee, and chocolate are best let alone. Coffee, one small 
cup, may be allowed for breakfast ; or cocoa, which is better, 
if made with a good deal of milk. Water should be drunk 
regularly, and it is not unlikely that much of the benefit 
derived from visiting foreign spas is on account of the regu- 
lar drinking of water. A good rule is for the patient to 
drink a glass of water before meals, while dressing, a glass 
of water or other fluid at each meal, a glass of water about 
two hours after meals, and before going to bed. If pre- 
ferred, bottled table waters may be used. Vichy water 
may be substituted for plain water once or twice a day. 
Tobacco is harmful in some cases. 

Enforcement of these dietary laws will in many cases over- 
come constipation. It is best not to resort to medicines to 
procure a good daily movement of the bowels, if it can be 
avoided. Kneading of the bowels when in a recumbent posi- 
tion will often stand us in good stead, the bowels being 
steadily and deeply rubbed with the heel of the hand, starting 
in the right groin, and following the course of the large in- 
testine upward, across, and downward. The habit of going 
to stool at a regular hour of the day should be formed, and 
it should be seen to that the bowels act promptly. If we 
must needs give medicine, the tablet triturates of aloin, 
belladonna, and nux vomica ; the pill of iron and aloes ; 
the extract of cascara sagrada, with or without nux vomica, 
which may be administered in capsules to avoid the dis- 
agreeable taste ; Startin's mixture — 

R 



Magnesii sulphatis, 


3 v J-3>s; 


20-30 


Ferri sulphatis, 


3J; 


3 


Ac. sulphur, dil., 


3y; 


6 


Syr. pruni virgin., 


fj; 


24 


Aquae, 


ad Jiv; 


100 



M. 

Sig. A teaspoonful through a tube, after meals. 

or any other serviceable remedy may be given. Hardaway 
recommends the phosphate of sodium, a teaspoonful in hot 
water before breakfast, or three times a day, for lithsemic 
patients who are constipated. This is an excellent laxative 



166 DISEASES OF THE SKIN. 

for children, a little of it being put into their milk, to which 
it gives a hardly noticeable salty taste. 

Exercise in the open air is as necessary for our eczema- 
tous patients as for any other class. It should not be taken 
so as to cause over-fatigue. Patients with eczema on the 
face and hands, or with a tendency thereto, should always 
wear gloves during the cold seasons, and should always 
protect the skin of their faces by a little powder or vaseline 
before going out into the cold or storm of wind or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic has come down from 
old with a reputation for curing eczema, and is largely pre- 
scribed. It had best be let alone. It is only of benefit in 
chronic scaling cases, and only in a few of them. It may 
be used in the form of Fowler's solution (Liq. potassii 
arsenitis), giving from 2 to 5 minims ; or as arsenious acid, 
in tablet triturates, either with or without pepper, dose ^ 
to -g 1 ^- grain. The wine of antimony in 5-minim doses, three 
times a day, has been warmly commended. Phosphorus, 
TFo" t° 2V g ram > either in pill or in oil, has been found 
useful in long-standing eczema. Piffard speaks well of an 
infusion of viola tricolor in acute or chronic eczema capitis, 
specially in lymphatic children. It is made by putting one 
or two drachms of the herb into a bowl, pouring a pint of 
hot water over it, and covering with a plate. When cool, 
it is to be taken in divided doses during the day. After a 
few days it generally aggravates the disease, a good thing 
to accomplish in chronic cases. It is then to be discontinued 
for a few days or a week. In acute cases the dose should 
be quite small. Turpentine, the spirits, is recommended 
by Crocker in obstinate cases. It is given in an emulsion 
with mucilage, three times a day, after meals : the dose 
being 10 minims at first, and then, if tolerated, increased 
by 5-minim doses up to 20 or 30 minims. While it is 
being taken, not less than a quart of barley-water should 
be drunk, and the last dose should be taken not later than 
six o'clock in the evening. The same author recommends 
counter -irritation over the spine, the nape of the neck for 



ECZEMA. 167 

eczema of the upper half of the body, and over the last 
dorsal and first lumbar vertebrae for the lower half. Dry 
heat, a mustard-leaf, or liquor epispasticus, may be used. 
I have seen most excellent effects from this plan. The 
spinal ice-bag sometimes accomplishes the same result. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by re- 
ducing the congestion of the skin. In chronic eczema, even 
without evident renal derangement, the acetate of potash in 
15-grain doses will prove useful. The itching may be so 
severe in some cases that even our local remedies may not 
allay it, and it may seem necessary to give some medicine 
to procure sleep. Never use opium. The bromides, chloral, 
or phenacetine may be given. Bulkley recommends tincture 
of gelsemium, of which ten drops are to be given, and re- 
peated and increased every half-hour till relief is obtained, 
or constitutional symptoms of languor, tranquillity, dizzi- 
ness, impairment of vision, and drooping of the lids, are 
produced. Quinine, in J-grain to 15-grain dose given at 
bed-time, is commended by some for the same purpose. 

Local Treatment. In all cases, whether due to purely 
local causes or a combination of these and some general 
cause, local treatment is of the greatest importance. The 
books teem with prescriptions which have been found effi- 
cacious, and some of them contain so many ingredients that 
it is hard to determine with exactness to what the good is 
due. After all, the matter is very simple, and if the prin- 
ciples are mastered, little difficulty will be found in accom- 
plishing the desired end. In acute cases employ soothing 
remedies ; in subacute cases use astringent and slightly 
stimulating remedies ; in chronic cases stimulate ; in all 
cases protect the skin from external irritation. It is better 
to learn how to use a few remedies and to know what to 
expect from them than to try every new method that appears 
in the medical press. 

It is a good broad rule that water should not be used on 
an eczematous skin, as it removes the newly formed epi- 
dermis and exposes the tender skin to the air. In all but 
chronic cases it should be used sparingly, and only to re- 



168 DISEASES OF THE SKIN". 

move dirt, or crusts, or scales, and the skin should be at 
once covered with some protecting powder or ointment. If 
water is used, it should be either rain or boiled water, or 
water with a little soda, one drachm to the basinful, or bran 
in it. 

In acute eczema lime-water, liquor plumbi subacetatis 
dil., lead and opium w T ash, or solutions of borax or soda, 
one or two drachms to the pint, may be sopped on three or 
four times a day, dusted over with corn starch, bismuth, 
lycopodium, kaolin, or French chalk, and covered with light, 
old linen or muslin. All these will allay the itching, but if 
this is especially severe the following may be used : 



Be. Camphori, 
Zinci oxidi, 
Amyli, 

Startin recommends the following : 



3ss; 

3\j; 
3^; 


3 
15 
30 


5ss; 


6 


? fr ; 


2 


3 vij ; 


12 
100 



M. 



& . Zinci oxidi, 

Pulv. calamine prep., 

Glycerini, 

Liq. calcis, ^ vij ; 100 M. 

As soon as the early and most acute stage is passed, a 
protecting and soothing ointment is to be used, and of these 
no one is safer than the standard benzoated oxide of zinc 
ointment that usually can be obtained anywhere. The 
cucumber ointment is also soothing. If the case be one in 
which there is much discharge, as in pustular, vesicular, and 
weeping eczemas, Lassar's paste is better than the oxide of 
zinc ointment, as being a paste it allows the discharge to 
percolate through it. It is made as follows : 



H.z™di,| u 3ij; 15 

Vaselini, ad ^ss; 30 



M. 



The addition of 10 or 15 grains of salicylic acid to the 
ounce increases its anti-pruritic quality. The only difficulty 
is that it takes time and muscle to make, and but few drug- 
gists make it well. See that in it, as in all other ointments, 
there are no gritty particles left. All ointments must be 



ECZEMA. 169 

smooth, or they do harm rather than good. In using oint- 
ments in eczema they should be evenly spread upon cheese- 
cloth folded four times, or upon old linen or muslin, in a 
layer as thick as the back of a table-knife, applied to the 
affected part and bound down snugly with a bandage. They 
should be changed twice a day, or more often if the dis- 
charges are profuse. 

Painting a limited moist patch of eczema with a solution 
of nitrate of silver, 3 to 10 grains to the ounce, is often a 
most prompt method of curing the disease. 

In subacute eczema these same ointments may be used 
for a time. The diachylon ointment will sometimes prove 
beneficial. Most cases that we are called upon to treat are 
in or near to the subacute stage, as the acute stage soon 
passes off. It is always advisable to begin treatment not 
too boldly. If our protecting and astringent remedies do 
not cure the case after a fair trial, then we must add stimu- 
lants, and of these one of the most reliable is tar, adding it 
at first in the proportion of about fifteen drops of the oil of 
cade to the ounce of ointment base, such as oxide of zinc 
ointment. 

In chronic squamous eczema we need stimulation to whip 
up the circulation, to produce absorption of the infiltration 
of the skin, and to promote a return to health. Here tar 
is one of our most reliable remedies, and it can be used in 
various strengths and ways. We may use the oil of cade, 
oleum cadini, the oil of birch, oleum rusci, or pix liquida. 
There is some doubt and difficulty about obtaining genuine 
oleum rusci, which is largely used by tanners in the prepa- 
ration of Russia leather. The oil of cade is most used. Some 
prefer this ointment : 



R. 01. cadini, 3 ss -j;l aa 2-4 

Zinci oxidi, 3ss-j ; / 

Unguenti aquae rosse, ^j ; 30 



M. 



Or the cade may be added to the oxide of zinc ointment in 
the proportion of a drachm to the ounce. Or pix liquida 
may be substituted in about double the strength. 

Another most excellent way of using tar, and preferable 






170 DISEASES OF THE SKIN. 

to the latter because not so liable to stain the clothing, is 
that proposed by Pick, namely : To make a strong tincture 
of tar, using 40 parts of pix liquida to 20 parts of alcohol. 
To paint the part every night with three coats of this 
tincture, letting each coat dry on before another is applied. 
Then cover with oxide of zinc ointment; the ointment being 
changed morning and night. 

Bulkley in some cases recommends tar in what he names 
liquor picis alkalinus, which is made as follows : 



R 



Picis liquid*, 


.lij; 


25 


Potass, causticae, 


,lj; 


12 


Aquse, 


3v; 


ad 100 



M. 



Dissolve the potash in the water and add slowly to the tar 
in a mortar with friction. This is to be used diluted twenty 
or more times with water, and followed by oxide of zinc 
ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared over 
the body. In some cases the tar will give rise to systemic 
poisoning, the urine will become black, and the patient will 
suffer from headache, oppression, nausea, vomiting, and 
diarrhoea, and the pulse will become frequent. Of course, 
under these circumstances the tar must be stopped. 

Sulphur is, next to tar, one of our best stimulating reme- 
dies in squamous eczema. It is not so reliable, as it is more 
uncertain in its effects. It finds its best use in circumscribed 
patches, and may be used in vaseline or simple ointment in 
the strength of one or two drachms to the ounce. In some 
skins it produces a good deal of dermatitis. 

Green soap is often of the greatest service in chronic 
eczema. It is to be used in the following way : Take either 
the green soap or Bagoe's prepared olive soap, warm Avater, 
and oxide of zinc ointment spread on muslin or linen. 
Dip a piece of flannel in the soap and then in the water, 
and then with it scrub the part vigorously until all the 
scales are removed and the skin looks somewhat raw. 
Now wash off all the soap with plenty of water, dab the 



ECZEMA. 171 

part dry with a soft towel, immediately cover with the oint- 
ment, and apply a bandage. The soap is to be used once a 
day and the ointment changed twice a day. 

Caustic potash,. 15 grains to 1 drachm to the ounce; or 
salicylic acid, 10 to 15 per cent., in ether, may be used to 
reduce very much thickened patches. Nitrate of silver, 10 
to 15 grains to the ounce, may also be used. 

Unguent. Jiydrarg. ammoniat., diluted to half its strength, 
is of use in chronic eczema of limited area. 

Ichthyol and resorcin are two of the more recent addi- 
tions to our armamentarium. The former has a more dis- 
agreeable odor than tar, and Crocker says of it : " We do 
not want more of such- remedies, as tar fills that place so 
well ; what is required are remedies which do not stain nor 
smell." Resorcin in from 2 to 5 per cent, strength is a 
good stimulating application. 

For the reduction of infiltration and removing the scales 
in a chronic eczema nothing is better for a time than sheet 
rubber applied to the part and bound down with a roller 
bandage. The rubber should be removed once a clay, 
sponged off with soda and water, and reapplied. The relief 
to the itching procured by this means is sometimes surpris- 
ing. As soon as the infiltration is reduced we should resort 
to our tar remedies for completion of the cure. 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin diseases. 
Thus we have the plaster mulls of Unna, in which a plaster 
mass is incorporated with the mulls. Many speak loudly in 
tbeir praise. Then collodion and traumaticine have been 
used, and answer well, the tar, salicylic acid, or what not, 
being dissolved or held in suspension. In this way chrys- 
arobin may be used on limited patches of chronic eczema. 
Gelatin preparations have been introduced, but they take 
so long to dry as a rule that they have not become popular 
in this country. Bassorin paste and plasment have been 
recently brought out, and promise well. Medicated soaps 
have their advocates. I have had no experience with 
them. 

Massage sometimes does good service in reducing in- 



172 DISEASES OF THE SKIN. 

filtration, the part being stroked upward in the course of 
the circulation. 

Baths are not usually advisable in eczema, and are ap- 
plicable only to chronic cases. Good results have been 
reported from some sulphur baths. Residence at the sea- 
side generally proves bad for eczematous patients, but it 
may be a good thing for some run-down patients, the tonic 
effect of the sea- air out-balancing the evil effect of the damp- 
ness. Soda, borax, or bran baths will prove grateful in 
some cases. Bulkley orders the following : 

R . Potass, carbonat., ^ iv ; 

Sodii carbonat., ^ iij ; 

Boracis pulveris, J ij ; M. 

Add to thirty-gallon bath with half a pound of starch. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with Assuring. It usually extends up the 
whole internatal fold. It gives rise to great pain in defeca- 
tion and to much itching at all times. The discharge from 
this form, as well as from eczema of the genitals, is frequently 
offensive. Excessive use of tobacco predisposes to this 
variety of eczema, probably on account of the nervous irri- 
tation inducing itching, for the relief of which the patient 
scratches and produces the eczema. 

In treatment the first thing is to stop the use of tobacco, 
a hard task, as the patient is ofttimes incredulous of its effi- 
cacy. Horseback riding and much walking will sometimes 
have to be stopped, as they may aggravate the trouble. If 
hemorrhoids or fissures of the mucous membrane are present, 
as they quite frequently are, they must be cured in order to 
obtain a permanent cure of the eczema. The bowels must be 
kept easy by laxatives so that one soft movement may be had 
each day. Liver derangements must be corrected to prevent 
portal congestion, and dieting will be of service. The nates 
must be separated by folds of lint, and the parts kept 
scrupulously clean, though water should be used as sparingly 
as possible. The itching may be relieved by sopping on 
hot water, dabbing the part dry, and making the chosen 



ECZEMA. 173 

application. Tar or diachylon ointment may be used, all 
covered in with a dusting-powder. Usually the drier the 
parts can be kept the better. Painting a limited surface with 
salicylic acid, 10 to 15 grains in an ounce of flexible collo- 
dion, is often followed by the happiest results. Painting with 
nitrate of silver, 10 to 15 grains to the ounce, is sometimes 
advisable. Here, too, if there is much thickening, wearing 
rubber cloth for a few days will greatly hasten the cure. 
A well applied T-bandage is the best way of keeping dress- 
ings in place. 

Eczema Aurium. Eczema may affect both the ear itself, 
and the inside of the auditory canal. When the ear is 
acutely affected it is swollen at times so much as to stand 
out from the head. In acute eczema of the external audi- 
tory canal, which is secondary to that of the auricle, the 
swelling may be so great as to cause dulness, if not loss of 
hearing. Of eczema of the outer part of the ear nothing 
special need be said excepting that the dressings must be 
exactly applied to all the little furrows of the ear, and it 
must be seen to that a pledget of lint is placed in the fur- 
row behind the ear so that it is separated from the side of 
the head, that in sleeping the two surfaces of skin do not 
come into contact. Painting this part of the ear with a 
solution of nitrate of silver, ten grains to the ounce, will 
sometimes aid greatly in converting a moist eczema into a 
squamous one. During the day a cure will be hastened by 
having the ear covered with a linen bag made in the fashion 
of an ear-muff. Eczema of the auditory canal is sometimes 
very annoying on account of the excessive itching, or on 
account of an accumulation of scales dulling the hearing. 
For this condition an ointment of tannin, one drachm to the 
ounce ; a solution of nitrate of silver, five to twenty grains to 
the ounce ; either of these is to be applied thoroughly by 
means of absorbent cotton on a probe, the ear being properly 
lighted by means of a head-mirror, and the operator having the 
requisite skill. Otherwise the tannic acid ointment or one 
of oxide of zinc, or the diachylon ointment, may be applied 
on pledgets of lint rolled up to fit the orifice. The insuffla- 
tion of boric acid will sometimes be better yet. The ear 



174 DISEASES OF THE SKIN". 

should not be syringed out often, and when it is necessary 
to do it a solution of borax or soda should be used. 

Eczema Barbae is scarcely ever confined to the bearded 
portion of the face, but it generally runs over on to the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has eczema 
capitis. It needs to be diagnosticated from ringworm and 
sycosis, which see. In treatment, shaving, or cutting the 
hair close, which is better, should be practised so that 
remedies may be closely applied. Plucking the hair from 
the pustules is to be recommended. Its further treatment is 
the same as that of Eczema capitis. It is an obstinate form 
of eczema, prone to relapses. 

Eczema Capitis. The scalp is very commonly the seat of 
eczema either by itself or in connection with eczema else- 
where. It has received various names, such as crusta lactea ; 
porrigo ; melitagra ; scalled head ; milk crust ; or vesicular 
or running scall. While any variety of eczema may occur 
on the scalp, the vesicular is very rarely seen, and the most 
common is the pustular, and the final stage, the squamous. 
In the acute stage the scalp may be swollen and boggy, and 
moist, with the hair stuck together. Usually we find the 
scalp crusted with a yellowish serous crust, but more com- 
monly with a greenish or blackish purulent crust, while the 
scalp is swollen but little. In some cases of pustular eczema 
there will be discrete, rather larger pustules scattered 
through the hair, besides moist and crusted patches. The 
hair is always matted together, and the odor from the scalp 
unpleasant. If the crusts are removed they will soon re-form. 

In both the erythematous and squamous forms the scalp 
is red and scaly. In the latter variety there is apt to be 
more or less thickening of the scalp, and in very severe 
cases the scalp may be cracked. Not infrequently there 
will be squamous patches in some places and moist and 
crusted patches in other places. 

With eczema of the scalp there is almost always eczema 
behind the ears. The cervical glands are very often swol- 
len, especially in children, but they need give no anxiety, 
as they very rarely suppurate. In the chronic form there 



ECZEMA. 175 

may be loss of hair, especially in children, when it is some- 
times mechanically rubbed off from the occiput. It is never 
permanently lost. All forms are itchy, the pustular form 
least so. The patient may complain of a " drawn " feeling 
of the scalp. As in all inflammatory diseases of the scalp 
there is over-activity of the sebaceous glands, and the crusts 
will contain a certain amount of fat. In chronic cases there 
may be, on the other hand, a deficiency of fat. Pediculi 
are often found on the hair. The disease may affect the 
whole scalp or only a portion of it, and may run an acute 
or chronic course. 

Etiology. The exciting causes of eczema capitis are all 
irritants to the scalp. Sometimes it is well meant but badly 
directed efforts at cleanliness, especially in children. Comb- 
ing with a fine-toothed comb, too vigorous use of soap and 
water, the use of a too stiff brush, are some of these. 
Pediculi are very often the cause — not the pediculi them- 
selves, but the scratching to relieve the itching produced by 
them. An eczema of the occiput should always suggest 
their presence, and search then will generally reveal the 
pediculi or their nits upon the hair. Sometimes remedies 
used to kill the lice will set up an eczema, such as strong 
mercurial ointments. In most cases eczema of the scalp is 
but a part of a more or less general eczema and due to the 
same causes. 

Diagnosis. The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythematosus, 
a dermatitis, psoriasis, seborrhcea, favus, pediculosis, and 
syphilis. See under these diseases. 

Treatment. The treatment of the disease is along the 
same lines as is that of the disease in general. On the 
scalp it is always best to use our remedies either in 
vaseline or oil, as preparations of lard make a disagree- 
able mess with the hair. Nor should a thick ointment ever 
be used, excepting perhaps in children before their hair 
is grown, or on bald heads. If there are crusts on the 
scalp they must be removed before any local treatment is 
used. This may be done best by soaking them with oil for 
twelve or twenty-four hours, and then washing them away 



176 DISEASES OF THE SKIN. 

with soap and water. Plenty of oil must be used, and it is 
well to tie the head up in a towel over night. A woman's or 
half-grown girl's hair should never be cut in order to treat the 
scalp. In applying remedies to the scalp, afier the acute stage, 
they should be worked in and not merely smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without one per cent, of carbolic acid, 
forms a good application. 

In subacute and chronic eczema of the scalp, tar, especially 
the oil of cade, is our most reliable remedy. It must be 
remembered that it can be used much earlier on the scalp 
than elsewhere, and most cases will improve under it as 
soon as the acute stage is passed. It may be begun in the 
strength of twenty drops to the ounce of oil, and increased 
to one or two drachms to the ounce. Many people object 
to the odor of the tar. We can substitute for it : 



Or, 



K . Hydrarg. ammon., gr. xx ; 1 15 

Vaselini, %y, 30 1 M. 

R. Ac. salicylici, gr. xx-xxx ; 1.5—2] 

01. olivaj, |j ; 30! M. 



The oil of cajuput in five to ten per cent, strength may 
be tried. Neither of which is as good as tar. 

If the disease is in a chronic condition shampooing with 
green soap or its tincture, followed by some oily, not very 
stimulating application, will prove curative. In this condi- 
tion it is sometimes best to exhibit the tar in an alcoholic 
solution. Rcsorcin in three to ten per cent, strength may 
be used cautiously in this way. If the scalp is cracked and 
thickened, great and prompt amelioration will be secured by 
having the patient wear a close-fitting cap of rubber. 

Eczema Crurum. Eczema of the legs acquires its pecu- 
liarities from the fact that the circulation of the parts is less 
active than it is in the upper portions of the body, on ac- 
count of the action of gravity upon the returning venous 
blood. It usually is seen as an eczema madidans, though 
any form may be present. Varicose veins, either super- 
ficial or deep, predispose to it. Pigmentation of more or 



ECZEMA. 177 

less dark-brown color follows or accompanies it, if of any 
chronicity, and occasionally purpuric spots will be scattered 
about the chronic patch. In treatment nothing special 
need be said except that it is always advisable to have the 
legs bandaged snugly from toes to knee, and that the best 
results will be attained when the bandaging is done by the 
doctor or a trained nurse. 

Eczema Genitalium often causes a great deal of discom- 
fort on account of the excessive itching that accompanies it. 
It affects the scrotum most commonly, which in some cases 
will be greatly thickened and feel like leather. The skin 
of the penis also suffers at times as well as the glans. In 
women, both the lesser and the greater lips of the vulva 
may be affected, and show excoriations and thickening, as 
well as the entrance to the vagina. All forms of eczema 
may be encountered in the genital region. In chronic eczema 
of the penis the organ becomes greatly enlarged both later- 
ally and longitudinally, on account of the thickening of the 
skin. The disease may be confined to the genitals or extend 
to the thighs, or the anal region. The presence of diabetes 
should always be suspected in a case of this kind, and the 
urine should be examined for sugar. Leucorrhcea is a 
common cause of the disease in women. 

Treatment. In the treatment of eczema of the genitals, 
apart from that due to general conditions and specially to the 
diabetes, it is essential that men should wear a well-fitting sus- 
pensory bandage, inside of which the dressing may be placed. 
The itching may be greatly relieved in all forms by directing 
the patient to sit over a vessel containing hot water and to sop 
the water up on the parts. The skin should be mopped dry, 
the oxide of zinc ointment, diachylon ointment, or Lassar's 
paste immediately applied, and the suspensory bandage ad- 
justed. Carbolic acid, one or two drachms to the ounce of 
glycerin and water, may also be used, lightly dabbed on, for 
the purpose of allaying the itching. It should be followed 
by either of the above ointments. For chronic, thickened 
eczema wearing sheet rubber inside of the suspensory ban- 
dage will give positive and immediate relief, and greatly 
reduce the thickening. After a few days it is well to follow 

8* 



178 DISEASES OF THE SKIN. 

it with a tar or resorcin ointment. In some cases nothing 
will do so well as the application of nitrate of silver, as 
already indicated. The spirits of nitrous ether may be 
used as an excipient of this. Hardaway speaks highly of 
rubbing the scrotum with a solution of salicylic acid in 
alcohol, one drachm to the ounce, and following this with a 
boric acid or diachylon ointment. 

Women should use a T-bandage instead of the suspensory. 
Otherwise the treatment is the same. In them I have seen 
the nitrate of silver treatment do remarkably well. 

Eczema Intertrigo occurs wherever folds of skin come 
into contact, and requires that the parts should be kept 
separate and as dry as possible by means of a dusting- 
powder, or by placing a piece of old linen or cheese-cloth, 
spread with the appropriate ointment, between the apposed 
folds of skin. For a dusting-powder we may use either 
corn starch alone or with bismuth, or zinc oxide. Lyco- 
podium is also an excellent powder. The disease often re- 
sembles an erythema, but inasmuch as both diseases are 
amenable to the same treatment, absolute accuracy of diag- 
nosis is not essential. Kaposi has seen gangrenous and 
diphtheritic inflammation begin in an intertriginous eczema. 

Eczema Labiorum is usually due to a nasal catarrh, and 
can be cured only when the cause is removed. Eczema may 
occur all about the mouth in an orbicular manner. Many 
people suffer from chapped lips, especially in winter. This 
is an eczema of the vermilion border. For this little can 
be done except to caution the patient against moistening the 
lips. Greasing the lips every night with camphor-ice or the 
like keeps them in good condition. Glycerin agrees well 
with some skins, and is harmful to others. Cracks may be 
touched with the nitrate of silver stick, and the lip painted 
with compound tincture of benzoin. 

Eczema Mammarum et Mammellarum. One of the most 
annoying accidents to befall a nursing woman is eczema 
of the nipples. They become excoriated and fissured, the 
cracks sometimes extending to the base of the nipple. At 
times a drop of pus can be squeezed from the bottom of the 



ECZEMA. 179 

crack. They are exquisitely sensitive, and every time the 
baby takes hold the woman suffers agony. The moisture 
from the child's mouth and the decomposing milk left on 
the nipple aggravate the trouble. Mastitis may complicate 
matters. In the intervals of nursing the nipple scabs over. 
Either one or both nipples may be affected. The disease 
may extend on to the breasts, or the breasts may be affected 
independently of the nipples. Women with pendulous and 
heavy breasts frequently suffer with a moist eczema in the 
sulcus beneath them. Apart from this nothing special need 
be said about eczema of the breasts. There is one disease 
of the breasts, called Paget's disease of the nipple, which 
at first very closely resembles eczema, and it is a question 
whether it is carcinomatous all the way through, or an 
eczema developing into a carcinoma. (See Paget's Disease 
for diagnosis.) 

Treatment. It is often possible to cure eczema of the 
nipples even while the child nurses. Sometimes it will be 
necessary to wean the child. Women during the latter 
months of pregnancy should handle their nipples every day 
and bathe them with whiskey or alcohol, to which may be 
added 20 or 30 grains of borax to the ounce. This will do 
much to prevent future trouble. The nursing having begun, 
the nipples should be carefully washed off and dried with a 
soft handkerchief, and dressed with oxide of zinc or diachylon 
ointment, should eczema show itself. Of course, the oint- 
ment should be removed before the infant is put to the 
breast, and this should be done with as little water and as 
much gentleness as possible. If there are cracks the child 
should nurse through a rubber nipple, and when it lets go 
the nipple should be dried and painted with compound 
tincture of benzoin, or the solution of nitrate of silver 
already spoken of. It is also advised to touch the cracks 
with the nitrate of silver stick. This is very painful, and 
of little use as long as the infiltration of the nipple that 
causes them continues. The nipples may be washed with a 
borax solution and covered with an ointment of borax. It 
is always advisable to use nothing that is poisonous in the 



180 DISEASES OF THE SKIN. 

dressings. Hardaway recommends the following for eczema 
under the breasts : 

R. Thymol, gr. j. 

Pulv. zinci oleat., ^j. M. 

Eczema Manuum. Eczema of the hands has been called 
"washerwoman's itch," "grocer's itch," "bricklayer's itch," 
and various other itches. It is in many cases a trade 
eczema, caused by strong alkaline soaps, or contact with 
sugar, mortar, or other irritant. It may arise independently 
of any of these trade causes, or it may be part of a general 
eczema. The acute forms, as they occur upon the backs of 
the hands, do not differ from the same on other parts of the 
body, and the same may be said of the chronic forms. The 
palms are seldom primarily affected, but secondarily to 
eczema of the wrists or fingers. The epidermis of the 
palms, as well as that of the inside of the fingers, is thicker 
than that of the other parts of the body, excepting the soles 
of the feet, and so the vesicles do not rupture readily, but 
are seen like little, more or less translucent grains under 
the skin. When they rupture, the skin is left more or less 
ragged and worm-eaten. The skin over all the joints is 
liable to crack and form painful fissures. Chronic eczema 
of the palms prevents free movement of them on account 
of the thickening and the painful cracking. The skin is 
reddened and covered with large adherent scales. Itching 
is intense at times. The whole palm may be affected, or 
the disease may form limited areas, as upon the center of 
the palm, over the thenar eminence, and upon the finger- 
ends. This form of eczema is often difficult of diagnosis 
from the squamous syphilide. The occurrence of the lesions 
upon one hand alone should rouse suspicion of syphilis, 
especially if little or no itching is complained of. 

Treatment. It is one of the most obstinate of eczemas 
to treat, and when of chronic form requires active stimula- 
tion by means of tar; salicylic acid; the soap and salve treat- 
ment ; rubbing in 5 to 10 per cent, of the oleate of mercury ; 
or painting with caustic potash. The constant wearing of 
rubber gloves is excellent for the purpose of softening the 



ECZEMA. 181 

skin and preparing it for other remedies. It is best to buy 
the canvas-lined gloves, turn them inside out, and wear the 
rubber next the skin. The hands must be kept out of 
water. Where this cannot be done, great care must be used 
in drying them. It is well to have the patient dry on two 
towels or before the fire, and then either to thrust the hands 
in a box of corn- starch powder or flour, or preferably to 
apply the proper dressings. 

Eczema Narium is often, if not always, associated with a 
chronic rhinitis. It is very obstinate. Crusts form on the 
inside of the nose, are picked off, re-form, and after a time 
ulcers result from the constant irritation. Sometimes in 
adults the disease locates itself about the hair follicles, and 
is very annoying. It is a not uncommon point of de- 
parture for recurrent attacks of facial erysipelas. If long 
continued it gives rise to a thickening of the upper lip. 
Furuncles sometimes complicate matters.' 

In the treatment of these cases the first attention must 
be given to the cure of the rhinitis. Then all crusts must 
be removed by soaking with oil. For the eczema we may 
use : 

R . Glycerole plumbi subacetat, \ 

Ungt. aquse rosse, J 1 ' ' M. 

as recommended by HardaAvay. 

Herzog 1 recommends the yellow oxide of mercury oint- 
ment, or equal parts of ungt. plumbi and vaseline, spread 
on lint and accurately applied to the diseased part. Urma 
rolls his zinc and red precipitate ointment muslin into a 
pledget and introduces it into the nose. In obstinate cases 
about the hairs, epilation by electrolysis may have to be 
performed. 

Eczema Palpebrarum is usually of an erythematous char- 
acter, and occurs as part of the same disease elseAvhere. 
Eczema of the cilise, also called blepharitis ciliaris, is 
always pustular. The edges of the lids are swollen, rounded, 
and more or less thickly strewn with pustules or crusts. 

1 Archiv f. Kinderheilk., 1887, p. 211. 



182 DISEASES OF THE SKIN. 

The lids stick together on waking in the morning. In the 
squamous form the edges of the lids are merely red and 
scaly. It is almost always symmetrical, occurs usually in 
strumous subjects, and is due to conjunctivitis. 

Treatment. The lids should be anointed before going 
to sleep in order to prevent their sticking together. I have 
always found the following ointment, as given by my friend, 
Prof. D. Webster, of the New York Polyclinic, most excellent : 

R. Ac. salicylici, gr. x ; 18 

Ungt. hydrarg. oxid. rubra, £j ; 5 

Ungt. aquae rosse, 3 v j; 30, M. 

An ointment composed of — 

Jjt . Hydrarg. oxid. flav., gr. ij-viij ; 

Vaselini, %] ; M. 

is recommended by Hardaway. Resorcin, 3 grains ; cold 
cream, 2J drachms, is editorially commended in the Mo- 
natshefte f. prakt. Dermat, 1888, vii. 1057. Whatever is 
used, we must be sure that any substance entering into it 
is in an impalpable powder, so as to avoid the possibility of 
getting anything gritty into the eye. Epilation may be 
necessary in some cases. 

Eczema Pedum. Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The greatest 
difficulty will be encountered in dressing the toes properly. 
For this the ointment should be spread upon a long and 
narrow strip of lint, the centre of the strip placed against 
the big toe, and the strip wound in and out between the 
toes. A piece of rubber sheeting cut to fit the sole and 
bound down with a bandage takes the place of the rubber 
glove. 

Eczema Unguium. Eczema may affect the nail fold 
alone, and the nail may be scarcely diseased, or the matrix 
and bed may be diseased, when the nail will lose its lustre, 
and become rough, uneven, striated, and atrophied. The 
nail may be depressed in the centre and turned up at the 



ECZEMA. 183 

end with an accumulation of scales under its free border. 
Usually eczema of the nails occurs as a part of a general 
eczema, but it may occur as an independent disease. 

It is best treated by means of cots made of rubber. It 
must be remembered that an ointment can never be used 
when rubber is, as it rots it. If the time has come, for an 
ointment, linen or leather cots must be substituted for the 
rubber ones. 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety, with 
a tendency to cracking about the creases of the joints and 
skin, exudation, scaling, and itching. These symptoms will 
serve to distinguish it from dermatitis exfoliativa, to which 
it bears a strong resemblance. Constitutional disturbances, 
such as fever and chills, loss of appetite, and digestive dis- 
orders are not uncommon in these truly pitiable cases, 
Furunculosis is apt to complicate matters. The patients are 
slow in recovering, and are apt to be a good deal pulled 
down by the disease. 

Treatment. These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaseline. 
The ordinary Carron oil, equal parts of linseed oil and lime- 
water ; cotton-seed oil with carbolic acid, 1 part of acid to 60 
of oil ; or simply smearing the body with vaseline and powder- 
ing on corn starch, will each relieve. Salicylic acid in oil, 1 
in 30 will also allay the discomfort. Alkaline baths, warm, 
and followed by one of the above, after tapping the skin gently 
dry, will also relieve, but the bath should not be used more 
than once a day. Its temperature should be about 98° F. ; 
it should last ten or fifteen minutes. Bulkley recommends 
anointing the skin before drying it, with — 

$ . Acid, carbolici, Bj - 3y; 3-16] 

Glycerite amyli, ^iv; 100 1 M. 

applying it freely. The best way of drying the skin is to 
envelop the patient in a warm sheet, and pat the skin dry. 
As the intensity of the eczema lessens, the frequency of the 



184 DISEASES OF THE SKIN. 

baths must be reduced. It will gradually cease from being 
universal, and become localized in patches. 

Eczema Infantile presents certain peculiarities that war- 
rant its being considered as a special form of eczema. It 
is very prone to be of the pustular variety, following the 
rule that in delicate or debilitated subjects an eruption upon 
the skin is apt to be pustular. While in adults eczema of 
the face is usually erythematous, in infants it is nearly 
always pustular. In them it is quite common, if not the 
rule, to have several regions affected at once, such as the 
scalp, the face, and the region of the crotch. In them, 
also, we have eczema madidans in these regions. While in 
adults that form of eczema is most frequently seen upon the 
legs, in infants it is quite exceptional. Eczema of the scalp 
in infants presents itself as a thick crust formed of purulent 
matter, epithelial debris, and sebaceous matter. This is 
called " milk crust." When the crust is raised the scalp 
will be found to be thickened, swollen, boggy, and moist, 
with a purulent secretion. The whole scalp maybe affected, 
or only the vertex. With it there will nearly always be a 
moist surface behind the ears, even though the face may be 
comparatively or absolutely free. The lymphatic glands 
will be swollen, but they seldom suppurate. When the face 
is affected it will sometimes be studded over with holes, 
superficial ulcerations, which, however, never leave scars. 
This appearance is seen very rarely in adults. It is often 
striking to note that the skin about the mouth and nose, 
and below the eyes, is in perfect health, though pale, while 
all the rest of the face may be involved in the most intense 
inflammation. The creases of the neck, the flexures of the 
joints, and the region of the genitals usually show an erythe- 
matous or a moist intertriginous eczema. At times the whole 
body will be affected with a general, but very rarely with a 
universal eczema. While the pustular and intertriginous 
forms of eczema are the most common, we may have all 
forms present at one time, and of them, the papular is most 
frequently met with. Itching is usually severe, keeping the 
little patient awake at night, and the tearing made by the 



ECZEMA. 185 

nails to relieve the itching gives rise to immense excoria- 
tions, especially of the face. 

Etiology. There are several causes tending to eczema in 
infants. Their skin is vulnerable to all irritants. When 
we consider that the child is born into the cold world sud- 
denly, and launched there out of a warm atmosphere, in 
which it was surrounded by an alkaline fluid, covered over 
with a fatty coating, and safe from the action of the atmos- 
pheric air, we can but wonder that its skin escapes as well 
as it does. More than one-third of the cases of eczema oc- 
curring before the fifth year of life occur in the first year. 
Add to the vulnerability of the skin the overzealous care 
commonly bestowed upon it for a few months after birth, 
and we have a good explanation for its frequence. Bad 
diet has much to do with its production. The vast majority 
of the little sufferers are nursed too often if at the breast, 
" every time they cry " being the rule ; or fed too frequently 
or improperly, " everything that is going" being again the 
rule. Inattention to the condition of the diapers is another 
active cause of the eczema about the genitals. Teething is, 
without doubt, an exciting cause, a fresh outbreak of eczema 
marking the eruption of a new tooth. Want of self-control 
in scratching is an aggravating circumstance. The frequent 
disturbances of digestion, so common at this period of life, 
predispose the infant's skin to eczema with rather more 
force than does the same disease in adults. Fat babies are 
frequent subjects of eczema, especially of the intertriginous 
varieties. 

Treatment. The treatment of eczema infantile is along; 
the same lines as that of eczema in adults. Special stress 
must be laid upon the feeding of infants, and strict rules 
must be laid down for the parents' guidance. The condition 
of the breast milk must be inquired into, as it is often of 
too poor quality to nourish the child. Women will some- 
times nurse their children far too long, with the idea of 
preventing conception. It is also very necessary to insist 
upon the child wearing a mask in eczema of the face and 
scalp. This may be made of light flannel or linen, a piece 
of the stuff being shaped somewhat after the shape of the 



186 DISEASES OF THE SKIN. 

face, with holes cut out for the nose, eyes, and mouth. A 
skull-cap is to be made, on to which the mask maybe sewed, 
or pinned with safety-pins. The ointment is to be spread 
upon lint or cheese-cloth- — a strip for the forehead, one for 
the chin, and one for each cheek. These are to be laid 
upon the face, and then the mask put over them, fastened 
to the skull-cap, and tied behind the head by two strings 
from its lower corners. It is astonishing what relief this 
affords to the itching, and how much more rapidly the case 
improves. The itching of the skin may be relieved by ap- 
propriate dressings, but if not it may become necessary to 
put the child in a home-made straight-jacket, by putting it 
in a pillow-case and sewing up the same between the arms 
and body. This is an extreme measure and should not be 
lightly adopted. In eczema of the crotch great care must be 
given to changing the napkins as soon as soiled. Fresh, 
clean ones must be put on, not those that have been dried 
without being washed. Dr. George H. Fox has called at- 
tention to a tight prepuce as a cause of eczema in male 
children. The urine dribbles away, so that a few drops wet 
the clean diapers, and thus keep up the trouble. In such 
cases judicious stretching of the prepuce may obviate the 
necessity for circumcision. Water must be kept from the 
skin in all cases. 

Internally, calomel in tablet triturates, one-tenth grain 
three times a day for three days, will give us good aid in 
many cases, even though the bowels are not constipated. 
Care must be taken not to produce too frequent and loose 
movements of the bowels. Other medication will be neces- 
sary, according to the nature of the case. Cod-liver oil will 
often cure a case which has been very obstinate. 

Prognosis. We can give assurances of curing eczema so 
far as the attack with which the patient comes to us is con- 
cerned. We can give no positive assurances that the disease 
will not return. The cure of the attack requires patience, 
careful study of the case, and the intelligent use of remedies. 
But there are some cases that are exceedingly rebellious. We 
have to accept the fact that some people are " eczematous," 
and that they cannot be permanently cured unless they 



ECZEMA SEBORRHOICUM. 187 

are regenerated. We should cure our cases as rapidly as 
we can, and not take refuge in the excuse of the incompetent 
man, and tell the patient that it is dangerous to cure it. 

Eczema Marginatum. See Trichophytosis. 

Eczema Seborrhoicum. Unna read a paper upon this 
disease in the Dermatological Section of the Ninth Inter- 
national Medical Congress at Washington in 1887, and pub- 
lished some papers upon the same subject in foreign journals 
at about the same time. From his first-mentioned paper 1 I 
shall quote largely in this section. He does not believe 
that there is such a disease as seborrhcea sicca, and employs 
the caption of this section as a substitute for the same. 

Symptoms. He teaches that the starting-point of almost 
all seborrheal eczemas is the scalp ; more rarely the margin 
of the eyelids, the axillae, bend of the elbows, or cruro-scrotal 
fold. Upon the head it exists mostly as an affection that is 
scarcely noticeable at its onset, and it is only after months 
or years that a sudden increase, loss of hair, an unusual 
amount of scaliness or collection of crusts, severe itching, 
or, finally, a circumscribed moist spot, or an evident eczema, 
leads the patient to consult a physician. The hair during 
the early stage is abnormally dry. A progressive alopecia 
pityrodes may show itself, the scaliness decreasing with the 
loss of the hair to make way for a hyperidrosis oleosa. Or 
the scaling and crusting may increase, a corona seborrhoica 
may form along the hair line, and the affection may extend 
upon the temples, over the ears to the neck, or on to the 
nose and cheeks. Or the catarrhal symptoms may be pro- 
nounced, and a moist eczema affect the scalp and ears, and, 
in children, the cheeks and forehead. 

. Next to the head, the sternum is a favorite site for the 
eruption, where it most Commonly assumes the crusted form, 
and most rarely the moist form. The crusted form is in 
round or oval spots the size of the finger-nail ; these group 
and partly coalesce, forming patches the size of a silver half- 
dollar, having a scalloped border. The color is yellow, with 
a delicate red border. These may clear up somewhat in the 

1 Journ. Cutan. and Gen.-urin. Dis., 1887, v. 440. 



188 DISEASES OF THE SKIN. 

centre and form circles, or break and form bow-shaped 
figures with the convexity outward. 

In the axillae we meet most commonly with the moist 
form, and here it shows a tendency to spread with rapidity 
upon the thorax. From the shoulders it spreads down 
upon the arms almost always in the crusted form, and 
shows a predilection for the flexor surface. The backs of 
the hands and fingers are often affected with a moist eczema, 
the trunk and arms escaping. 

Upon the palms and soles we find little heaped-up masses 
of scales corresponding to individual coiled glands and re- 
sembling psoriasis guttata. Later the epidermis peels off, 
but there is never any moisture. The crusted form gen- 
erally appears in rings or serpiginous patches on the trunk, 
buttocks, and hips. The cruro- scrotal fold and the approxi- 
mating surfaces of the thigh and scrotum are favorite loca- 
tions for the disease, probably forming here many of the 
so-called cases of eczema marginatum. The thigh and 
extensor surface of the knee are but little affected, while 
the popliteal space and the leg often are, either in the large 
papular or the thick-crusted form. 

Upon the bearded portion of the face, when the beard is 
worn, we find either a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and the 
unbearded portions of the face in men we have circum- 
scribed, scaly, yellowish or yellowish-gray, slightly elevated 
patches, mostly on the forehead, cheeks, and naso-labial 
fold. There may also be red papules, free from scales or 
with fine yellow ones, with redness of the skin between 
the papules. The face is the favorite location for a moist 
seborrheal eczema, in children especially. 

Diagnosis. The diagnostic points from psoriasis are : 
1. The spreading of the affection from above downward, 
mostly in the middle line of the body, and the stationary 
character of the lesions. 2. The history of a previous 
seborrheal affection. 3. The fatty and crumbling character 
of the scales, and the yellowish color. 4. The configuration 
of the separate lesions, the thickened papules spontaneously 
flattening out in the middle or one side; the red color 



ELEPHANTIASIS. 189 

changing to yellow ; and the scaly surface becoming smooth, 
to suddenly break out again at the margin in a raised, red, 
scale-covered, bow-formed wall. 

Treatment. The best remedy for the moist form is 
sulphur, and for the scaly and crusted forms, chrysarobin, 
pyrogallol, and resorcin. It is always necessary to direct 
special attention to the scalp and eyelids, as these are the 
foci from which the disease spreads. For the disease upon 
the back of the hand, it is recommended that the affected 
part be covered with a thin layer of lint soaked in the fol- 
lowing solution diluted one-half: 

R . Resorcin, ~l n A , 

rn . ' > aa 10 parts, 

(jrlycerm, J L 

Alcohol, dil., 180 " M. 

and over this a large piece of gutta-percha tissue is to be 
bound. This is to be used at night, and during the day it 
is to be kept dressed with a zinc-oxide paste with or without 
tar, sulphur, or resorcin. 

It must be added that a parasitic origin has been assumed 
for this disease, the parasite being yet undiscovered. On 
this ground a contagious element has been assumed. It 
will be seen on consulting the section on seborrhcea that 
the greater part of seborrhoeal eczema is but seborrhcea. 
Further investigation of the subject will doubtless elucidate 
many uncertainties regarding it. 

Elephantiasis (E 2 l-e 2 -fa 2 nt-i 2 -a'-si 2 s). Synonyms : Bar- 
badoes leg; Cochin-China leg; Glandular disease of Barba- 
does ; Sarcocele of the Egyptians ; Tropical big-leg ; Buc- 
nemia tropica ; Morbus elephas ; Pachydermia ; Spargosis ; 
Phlegmasia Malabarica ; Hernia carnosa ; Elephantiasis 
Indica seu Arabum. 

A chronic endemic or sporadic disease of the skin, char- 
acterized by hyperplasia of the skin and subcutaneous 
tissues, due to a stoppage of the lymphatics, affecting chiefly 
the lower extremities, and marked by enormous enlargement 
of the affected part. 



190 



DISEASES OF THE SKIN. 



Symptoms. In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 
America, the disease is endemic, but sporadic cases occur in 
all parts of the world. The symptoms of the two forms 
differ only in that in the endemic variety there is usually 
what is called a elephantoid fever," with lumbar pain, 

Fig. 16. 




Elephantiasis. (After Taylor.) 

nausea, and vomiting, and followed by sweating. The fever 
is of high grade, and bears a striking resemblance to mala- 
rial pyrexia. In sporadic cases the characteristic fever is 
wanting, though usually there is some constitutional dis- 
turbance preceding the local symptoms. In other instances 
the fever is altogether wanting. 



ELEPHANTIASIS. 191 

Locally the affected part is apparently attacked by ery- 
sipelas, or a deep dermatitis, phlebitis, or lymphangitis ; it 
becomes greatly reddened and swollen; and there may 
or may not be a clear or milky discharge from the skin, 
and an eruption of vesicles. After a time these symptoms 
subside, but the part does not return to its normal size, and 
there is some pitting of the skin on pressure. After a few 
months there is a repetition of the attack, and the part is 
left still more enlarged. And so the case progresses with 
varying periods of quiescence, and recurrent erysipelatous 
attacks, each one leaving the part more thickened than be- 
fore, until it attains enormous proportions. The normal 
contour of the part is lost; the folds of the skin are ob- 
literated ; and the surface is smooth and shiny. Now no 
impression can be made upon the swelling by pressure of 
the finger. Ulcerations are apt to occur, and some cases 
show varicose lymphatics which are tender and painful, and 
may rupture of themselves or by accident and discharge a 
clear or milky chylous coagulable fluid. The escape of this 
fluid saps the patient's strength. 

The parts most frequently affected are the legs, usually 
one, but may be both; and next to them, the male or female 
genitals. It occurs also on the arms, face, ears, female breast, 
and tongue. When the leg is the seat of the disease it becomes 
so large as to interfere with locomotion and compel the 
sufferer to take to his bed. The suface of the limb may be 
smooth ; or uneven on account of the varicose lymphatics ; 
or warty on account of enlargement of the papillae. The 
foot and leg may melt into each other, as it were, all trace 
of an ankle- being lost. Wherever there are two surfaces in 
contact, there is apt to be a decomposition of the sweat, 
sebaceous matter, and epithelium, giving rise to a foul odor 
like, but worse than, that of an ordinary intertrigo. The 
lymphatic glands in the groin are enlarged. Eczema may 
develop with its attendant itching. The appearance of this 
elephantine leg gave the name to the disease. When the 
scrotum is the affected part, vomiting often occurs in the 
febrile attacks, as well as pain in the groins along the 
spermatic cord and in the testicles. Hydrocele may develop, 



192 DISEASES OF THE SKIN". 

and the abdominal rings, over-stretched by the swollen 
cords, may give opportunity to the formation of hernia 
upon the subsidence of the acute symptoms. The scrotum 
may become so large as to reach the ground when the pa- 
tient is standing, and one case has been reported in which 
it weighed one hundred and ten pounds. One form of the 
affection is called " lymph scrotum or nsevoid elephantiasis," 
on account of the marked dilatation of the lymphatics. 

There are all degrees of thickening of the skin and sub- 
cutaneous tissues, but the recurrent attacks of erysipelas, 
and the progressive enlargement, are characteristic of all. 
The bones may become enlarged. This is a very rare 
affection, which is called " acromegalia." In the Lancet of 
June 11, 1887, several cases are reported, one of which 
was on exhibition in a travelling show as the " Elephant 
man." In his case the head attained massive proportions. 

Etiology. The disease occurs in both sexes and in all 
ages, but is most common in men of middle life and in the 
dark-skinned races. Moncorvo 1 reports a case in an infant 
four months old, and speaks of a case in one fifteen days old. 
He believes that it may develop in utero. Floras 2 reports a 
case beginning at birth and remaining stationary for fifteen 
years, when it took on the typical course of the disease. It 
is particularly prevalent in damp, malarious parts of the sea- 
coast. It is not supposed to be hereditary, though in 
countries in which it is endemic several members of the 
same family may be affected by it. Leprosy and elephan- 
tiasis have been accidentally associated. Exposure to cold, 
phlegmasia dolens, cellulitis, ulcers, lupus, repeated attacks 
of eczema or erysipelas, posture, as the hanging down of a 
limb on account of rheumatism, may give rise to the disease. 
In fact, any disease of the skin that is attended by repeated 
inflammatory outbreaks favors the occurrence of elephanti- 
asis. The filaria sanguinis hominis has been claimed to be 
the cause of the endemic form of the disease. It is not found 
in every case, and is rarely encountered in sporadic cases. 

1 Rev. mens, des Mai. de l'Enfance, 1886, iv. 101. 

2 Archiv. klin. Chirurgie, 1888, xxxvii. 598. 



ELEPHANTIASIS. 193 

Pathology. Anything that will occlude the lymphatic 
channels may cause the disease. In endemic cases it is the 
ova of the filaria that does this. In sporadic cases the 
several etiological factors play the same part. However 
caused, the result is an enormous hypertrophy of the sub- 
cutaneous tissues from increase of fibrous tissue in various 
stages of development. The corium is also increased in 
thickness, and there is proliferation of the epidermis, en- 
largement of bloodvessels, lymphatics, and nerves. In ad- 
vanced cases the muscles undergo fibro-fatty changes, and 
the bones become enlarged (Crocker). 

Treatment. The best thing for a patient with endemic 
elephantiasis to do is to go to a more healthful climate. The 
treatment of the patient during the exacerbations is purely 
symptomatic, with fomentations, quinine, iron, and the like. 
Various measures for the cure of the disease have been pro- 
posed, but none are perfectly satisfactory. Of course, the 
scrotal tumor may be cut off. The leg has been ampu- 
tated at the hip, a dangerous operation. Unfortunately the 
other leg has become diseased soon after the one has been 
cut off. Ligature of the femoral artery has been performed, 
but the result has not been satisfactory. Compression by 
means of a Martin's rubber bandage, or the ordinary roller 
bandage, will afford relief. When it is left off for a time, 
enlargement will again take place. It, of course, cannot be 
used while inflammation is present. Bentley 1 has reported 
the cure of a case by the daily inunction of a half-drachm 
of mercurial ointment twice daily, and the application of a 
firm bandage for fourteen days. After that the inunctions 
were made once a day. Internally he gave iodide of potash 
alone, or in this formula : 



R . Potass, iodid., ^ ij ; 1 

Potass, chlor., 3j ; 1 

Sol. hydrarg. perchlor., % ss ; 6 

Inf. chiretta, ad ^ viij ; 100 

Sig. % ss three times a day. 



M. 



Galvanism has produced alleviation, if not cure, in some 
cases. Hardaway has seen great amelioration in one case 



1 Lancet, 1878, i, 785. 
9 



194 DISEASES OF THE SKIN". 

by the use of Squire's glycerole of the subacetate of lead. 
Massage is beneficial. 

Prognosis. Unless exhausted by the loss of lymph the 
disease may last indefinitely without deterioration of the 
health. Death may result from pyaemia or thrombosis. 
The patient often dies from some intercurrent affection. 

Elephantiasis Grecorum. See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture of 
the pulmonary alveoli on account of vomiting or paroxysmal 
coughing, and the air making its way under the skin. The 
affected part looks swollen, feels cushiony, and gives a deli- 
cate crackling sound on palpation. There will be a history 
of the sudden occurrence of the swelling after coughing or 
vomiting, and probably more or less dyspnoea will be expe- 
rienced. The air slowly escapes, and the parts return to 
their normal condition. 

Endemic Verrugas. See Favus. 

Endothelcarcinoma. See Carcinoma. 

Endurcissement du Tissu Cellulaire. See Sclerema 
neonatorum. 

Engelures. See Dermatitis calorica. 

Ephelides. See Lentigo. 

Ephidrosis. See Hyperidrosis. 

Ephidrosis Cruenta. See Haematidrosis. 

Epidermolysis (E^-i^du^rm-o^'-P-s^s). Synonyms : Acan- 
tolysis bullosa (Goldscheide and Joseph) ; Dermatitis bullosa 
(Valentine). This is a rare disease, or rather peculiarity of 
the skin, in which bullae arise upon the slightest pressure. 
The disease shows itself in infancy, and occurs especially 
upon the hands and feet. The tendency to the formation of 
bullae lessens toward middle life. The lesions begin as a 
red spot, which is itchy. The bulla begins to form about 
two hours afterward, and keeps on enlarging for two or 
three days. It then gradually decreases, dries into a scale, 
which falls, leaving healthy skin. If the bulla is broken, it 
discharges a yellow, slightly sticky fluid, and leaves a sup- 



EPITHELIOMA. 195 

purating base. The disease is hereditary in certain families, 
and is most pronounced in summer-time. 

Epithelialkrebs. See Epithelioma. 

Epitheliom Kystique Benin. See Adenoma of sweat 
glands. 

Epithelioma (E 2 p-i 2 -thel-i 2 -o'ma 3 ). Synonyms : (Fr.) Epi- 
theliome cancro'ide ; (Ger.) Epithelialkrebs ; Cancroid, Skin 
cancer, Epithelial cancer, Noli me tangere. 

Epithelioma is a chronic, progressive, malignant new 
growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard waxy 
edges, and by a strong tendency to return in the scar after 
apparent removal by knife or caustic. 

Symptoms. Epithelioma always begins in a most inno- 
cent manner, and may be present for months or years be- 
fore the patient dreams that he has a serious disease. It 
may occur upon the skin alone, or upon the mucous mem- 
brane alone, or upon both the skin and mucous membrane 
at their line of juncture. Epitheliomas occurring upon the 
tongue, larynx, or uterus do not concern us here, as they 
belong to the domain of surgery. The starting-point of the 
disease may be a crack or an abraded scaly spot, as on the 
lip ; a small, flat, scaly, sebaceous patch ; a white, pearly- 
looking, hard nodule ; a senile or other wart or papilloma ; 
a pigmentary mole ; a cicatrix ; an adenoma; a chronic or 
lupous ulcer ; a psoriatic patch, or some other new growth in 
the skin. Some of these lesions may have been present for 
many years, as, for instance, a mole. Some appear but a 
short time before they frankly declare their nature, such as 
the waxy nodule. However it may begin, after a varying 
time ulceration occurs, the disease spreads at its edges, and 
the ulceration grows deeper and deeper, eating its way 
through skin, muscles, and bone in the infiltrating form, or 
creeping over the surface in the most superficial form. The 
lymphatic glands may be involved early in the course of the 
disease, or not for many years. Eventually they become 
swollen, hard, break down, and ulcerate, assuming the ap- 
pearance of an epitheliomatous ulcer. A typical epitheli- 



196 DISEASES OF THE SKIN. 

omatous 'ulcer is irregular in shape, with raised, hard, waxy- 
looking, rounded or everted edges, over which, quite com- 
monly, course dilated bloodvessels ; the floor is uneven, 
bleeds easily when touched, and is covered by a brownish 
crust, or a sanious, purulent secretion. Epithelomas are 
usually single lesions, but they may be multiple. Some 
years ago there was a patient in Dr. George H. Fox's ser- 
vice at the New York Skin and Cancer Hospital, who had 
scores of epithelomas developing from large, waxy, reddish 
nodules scattered all over his face. Sometimes a single epi- 
thelioma attains vast dimensions, involving the whole of one 
side of the face, scalp, and neck in one huge excavated ulcer. 
Sometimes before the characteristic ulceration develops the 
new growth may take the form of a single enlarged papilla, 
or a group of them. In some cases it may have a cauli- 
flower-like appearance, spreading out from a more or less 
narrow base. Fissures are apt to form between the papilla, 
and then there is usually an offensive discharge. This is 
called the papillary form. The most typical case of the 
cauliflower form that I have seen was on the vulva. 

Subjective symptoms are absent in many cases at first, 
but in the deep, infiltrating form pain of a lancinating char- 
acter is present. This often is so severe that the sufferer is 
robbed of his sleep. Sometimes there is no pain, and the 
patient experiences only the discomfort incident to the 
ulceration. 

The course of the disease is always chronic. Different 
cases show different degrees of malignancy. Some will 
prove fatal in four years or less ; some will last indefinitely. 
There is no tendency to recovery, though at times a partial 
attempt at healing will be made. I have watched one super- 
ficial epithelioma in an old Irishwoman, in Prof. E. B. 
Bronson's service at the New York Polyclinic, creep over 
the skin of the face, healing up in the older parts while 
spreading ahead. She refused active interference. While 
all epitheliomas show a strong tendency to return after 
operation and in the scar left by it, in some cases this ten- 
dency is much more marked than in others. Death results 
from exhaustion. 



EPITHELIOMA. 197 

While epithelioma may occur upon any part of the body, 
it is more frequently located upon the lower lip, where it 
occurs, according to Paget, in 50 per cent, of the cases. 
The next most common location is the face. Indeed, Thiersch 
met with it here in seventy-eight out of one hundred and 
two cases. The external genital organs of both sexes, and 
the anal region, more rarely, are other common sites. The 
upper lip is very rarely affected. A favorite location upon 
the face is upon the side of the nose and near the inner 
canthus of the eye. Here it is very apt to pass over on to 
the eyelids, and destroy them. Not infrequently it begins 
upon the eyelid itself. 

It is customary to describe a number of forms of epi- 
thelioma, but it seems to me much better, especially for a 
student, not to encumber his mind with too many names. 
The superficial, deep-seated or infiltrated, and the papillary 
forms have already been mentioned. The chimney-sweep's 
cancer is an epithelioma of the scrotum, met with in par- 
affin-workers and chimney-sweeps. The rodent ulcer 
used to be described as a special form of disease, but it is 
now considered to be an epithelioma. Clinically, it is sup- 
posed to be characterized by occurring on the skin of the 
upper half of the face, but running a slower and painless 
course by not involving the lymphatics, and by perpendicu- 
lar rather than lateral extension. 

Etiology. The cause of epithelioma is often obscure. 
We know that repeated irritation of a part is often followed 
by its advent. Smoking short clay pipes is not uncom- 
monly followed by epithelioma of the lip ; a ragged tooth 
accounts for many an epithelioma of the tongue ; the wear- 
ing of spectacles or eye-glasses has in some cases apparently 
caused the new growth upon the nose ; constant picking or 
inadequate attempts at the removal of warts and scaly spots 
would seem to account for epithelioma of the face ; and the 
scratching to relieve the pruritus of the anus may play the 
same part in producing the disease about the anus. This 
constant irritation would explain the appearance of epi- 
thelioma in paraffin-workers and chimney-sweeps, in chronic 
ulcers, psoriasis, old cicatiices, and the like. A congenital 



198 DISEASES OF THE SKIN. 

or acquired phimosis and the repeated inflammation due to 
decomposing smegma are the forerunners of the disease 
upon the penis. Age is the most pronounced predisposing 
cause. The disease is rare under thirty years of age, and 
increases in frequency beyond that period. Heredity has 
some influence, though Lewis has found that it is not so 
well marked as it is frequently assumed to be. Males are 
more often affected than females. It seems to have a pre- 
dilection for all neoplastic growths. The latest theory, 
unproven, is that of Darier and Wickham, who think that 
it is parasitic and due to psorosperms. (See section on 
that subject.) 

Pathology. Crocker sums up the pathology of the 
affection as follows : " The essence of the epitheliomatous 
process is the development of epithelium, and its infiltration 
into the deeper tissues where it does not normally exist, and 
where its presence produces irritation and consequent in- 
flammatory changes." " Cell nests, consisting of horny 
transformed cells in the centre, and of laminae of flattened 
epithelium externally, are characteristic of the disease, but 
are not present in every case, nor is their presence always 
necessary for a diagnosis." (Robinson.) 

Diagnosis. The disease must be differentiated from 
lupus, syphilis, papilloma, and seborrhoeal warts. From 
lupus it differs in an entire absence of brownish lupus 
tubercles ; in beginning late in life, as a rule, while lupus 
begins in early life; by its comparatively more rapid course; 
its lancinating pain; the involvement of the lymphatic 
glands; the deep ulceration; the waxy, raised, hard margin; 
and the development of the cancerous cachexia. From 
syphilis it differs in having a single and not a multiple 
lesion ; in its slower course ; in its showing no tendency to 
recovery ; in its not responding to internal treatment ; in 
its painfulness ; and in its waxy, raised, hard margin. From 
papilloma and seborrhoeal warts there are no positive diag- 
nostic marks of distinction. Either of the two diseases 
appearing late in life, or showing symptoms of activity at 
that time, should rouse our suspicions. 

Treatment. Complete and radical destruction of the 



EPITHELIOMA. 



199 



disease is the only thing to be done in the treatment of 
epithelioma. As a prophylactic measure it is well to de- 
stroy all suspicious warts appearing after middle life, and 
to apply appropriate treatment to seborrhoeal patches occur- 
ring at the same period. Superficial caustics should never 
be used to an epithelioma, as they only encourage their 
growth. The radical treatment will differ with the point of 
view, all surgeons inclining to the knife, while dermatolo- 
gists advocate the curette or powerfully destructive caustics. 
If the knife is used it must cut out a wide margin beyond 
the growth. Extirpation is especially applicable and the 
most appropriate treatment of epithelioma of the lip and 
penis. In the latter the organ must be amputated above the 
ulcer, if that has attained any size, and the inguinal glands 
likewise taken out. In all cases in Avhich the lymphatic 
glands have become involved they should be taken out. 

To all superficial epitheliomas and to many of the in- 
filtrating variety Schwimmer's plan of treatment will be 
applicable, and will prove curative. The growth is to be 
scraped out thoroughly with the dermal curette (Fig. 17); 

Fig. 17. 




The dermal curette. 



the diseased tissues will give way readily ; the bleeding is 
to be stopped by pressure ; and a pyrogallic acid ointment 
of 33 J per cent, strength is to be applied for from four to six 
days. Care should be taken that it be applied exactly to 
the growth, for though it exerts its greatest action upon the 
diseased tissues, it also acts upon the sound skin. This 
ointment will produce a black crust over the growth, on 
account of oxidation of the acid, and will cause a free dis- 



200 DISEASES OF THE SKIN. 

charge from the scraped surface during a few days. The 
discharge becomes less by degrees. After the end of four 
or six days the black crust is to be removed by covering it 
with carbolized vaseline for twenty-four or forty-eight 
hours. Last of all mercurial plaster is to be applied, 
under which the part will heal. This method has produced 
most satisfactory results in my hands, and is . not particu- 
larly painful if cocaine is used hypodermically before the 
scraping. 

Arsenic holds the first place among caustics. Marsden's 
paste, composed of equal parts of arsenious acid and gum 
acacia rubbed together and mixed into a paste with water 
just before using, is perhaps the most often used. It is 
dreadfully painful and often causes great oedema. It should 
be applied accurately to the affected part on linen, and left 
on for twelve to twenty-four hours, according to the patient's 
endurance. Poultices are to be applied after the paste, and 
kept on continuously till the slough separates. If the 
growth has not been destroyed, the process may be repeated. 
Lewis 1 has had good results from using Bougard's paste, as 
follows : 

R . Wheat flour, \ - - aa 

Starch, | aa 0U 

Arsenic, 1 



Cinnabar, 1 . _ K 

Sal. ammoniac, J 

Corrosive sublimate, 

Solution chloride of zinc @, 52°, 245 



50 



M. 



The first six ingredients are separately ground to a fine 
powder and mixed in a mortar. Then the solution of the 
zinc is slowly added while the mass is stirred. It is to be 
kept covered in an earthen jar. A portion is to be applied 
accurately to the part and kept on for thirty hours, and 
followed by a poultice. Lactic acid is another powerful 
caustic, to be applied by mixing it with an equal part of finely 
powdered silica and spreading it upon gum-paper. It is kept 
on for twelve hours and renewed twenty-four hours afterward. 

1 Journ. Cutan. and Gen.-urin. Dis., 1890, viii. 70. 






EQUINIA. 201 

Hardaway prefers to apply the syrupy acid by means of 
absorbent cotton for ten or fifteen minutes, and then wash 
off the excess of acid with water. This is done daily. 

The thermo- or galvano-cautery may also be used. Re- 
sorcin has its advocates, as has caustic potash, chloride of 
zinc, and the nitrate of silver. These may be of service 
where, for any reason, a more radical operation is not 
admissible. The chlorate of potassium in saturated solu- 
tion has in some hands done good. Fuchsin and methyl-blue, 
either injected under the skin or locally applied, will some- 
times seem to stay the progress of an epithelioma. 

There are some cases that are too advanced for any active 
interference, and the palliative remedies only are permissible. 

Prognosis. The prognosis of epithelioma as to life is 
fairly good. While, as already said, there are some cases 
that are rapidly fatal, many do not seem to have any effect 
on the patient's health for years. The prognosis as to cure 
is always doubtful. Some cases, whether excised or de- 
stroyed by other means, will return after a time. 

Epithelioma Contagiosum. See Molluscum. 

Epitheliomatose Pigmentaire. See Atrophoderma pig- 
mentosum. 

Equinia (E 2 k-wiV-i 2 -a 3 ). Synonyms : Glanders ; Farcy ; 
(Fr.) Morve ; (Ger.) Rotz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse. 

This is a rare disease in the human race, and runs an acute, 
subacute, or chronic course. It is derived by inoculation, and 
its symptoms show themselves in from three days to six 
weeks after it. Its constitutional symptoms are fever, pros- 
tration, constipation, and rheumatic pains, with the subse- 
quent development of a typhoid condition in which the 
patient dies. The objective symptoms are a profuse puru- 
lent or sanious nasal discharge ; chancroidal ulceration at 
the site of entrance of the poison ; phlegmonous inflamma- 
tion of the affected part ; adenitis ; and a cutaneous efflo- 
rescence. The latter is at first disseminated red macules 
developing into yellow papules, upon which variola-like 

9* 



202 DISEASES OF THE SKIN. 

pustules and bullae may form. These may coalesce into 
superficial ulcerations and gangrenous patches. Infiltration 
of the subcutaneous tissues may occur and deep sloughs 
may form. There may be a general adenitis, and the glands 
may break down and form ulcerating cavities. The whole 
skin may be involved in these destructive processes. 

Treatment. Treatment is usually unavailing, and is 
on general principles. The prognosis is bad. The more 
acute the symptoms the worse the outlook. 

Erbgrind. See Favus. 

Erysipelas (E 2 r-i 2 -si 2 p'e 2 l-a 2 s). Synonyms : (Fr.) La rose, 
Feu sacre ; (Ger.) Rothlauf, Rose, Hautrose, Wundrose ; 
(It.) Risipola ; St. Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin or the adjacent 
mucous membranes, attended always with redness and swell- 
ing, and often with vesicles, bulla?, pustules, diffuse sup- 
puration, and gangrene ; and characterized by a tendency 
to spread at the periphery and by fever. (Foster.) 

Symptoms. Though the most modern pathology teaches 
that erysipelas always originates in or about a lesion of the 
skin or mucous membrane, and is therefore allied if not 
identical with the same disease as met with in surgical and 
lying-in wards, so-called surgical erysipelas will not be con- 
sidered here. The outbreak of the disease is usually pre- 
ceded for a day or so with malaise, and the attack is often 
ushered in with a chill, pyrexia, and vomiting. The fever 
is present throughout the whole course of the disease, ex- 
cepting in the most mild type, when it may soon subside. 
The thermometric range is from 101° to 105.5° F. There 
will be other signs of constitutional disturbance, such as a 
coated tongue, a quickened pulse, either full, soft, and com- 
pressible, or, in bad cases, small and weak ; headache, 
drowsiness, or, in bad cases, delirium ; and sometimes albu- 
min is found in the urine. 

The most frequent location of the disease, as far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, sharply 
defined, irregularly shaped, hot to the touch, and, at first, 



EKYSIPELAS. 203 

with a smooth, glazed surface. The patch enlarges, creep- 
ing with more or less rapidity over the surface, always pre- 
serving its sharp, ofttimes indented border that is raised 
toward the sound skin ; it becomes of a darker hue, some- 
times livid ; and very commonly, though not uniformly, 
vesicles or even blebs form on it. These latter may become 
purulent, and breaking, discharge their contents upon the 
surface, which dries into crusts. As the process extends, 
the central portion becomes flattened and less red. Some- 
times new patches may appear, and coalesce with the 
original patch. Sometimes, while spreading peripherally, 
there may be a recrudescence in the older parts. The area 
of the disease may be limited or may include the whole 
body. A r ery often it seems to be checked by the line of 
the hair, whether of the whiskers or scalp. Not uncom- 
monly it invades the hairy parts, involving one-half or the 
whole of the scalp and extending down upon the neck. 
Then the patient's appearance is indeed deplorable. His 
lips are swollen and livid, his eyelids are swollen so that the 
eyes cannot be opened, and his head seems enormously en- 
larged. At times there may be a lighting up of the disease 
on a distant part of the body, as on the arm with erysipelas 
of the face. The lymphatics and the lymphatic glands are 
involved. The former often show themselves as red streaks. 
The glands may suppurate, and gangrene of the skin may 
declare itself. All grades of inflammation may be reached. 
Sometimes the disease is but slight, sometimes very severe, 
the constitutional symptoms keeping pace with the severity 
of the local symptoms. The duration of the disease may be 
six or seven days, or two or three weeks. The patient is 
always more or less prostrated by it, though many of the 
cases we see are ambulant cases. 

The subjective symptoms are burning, tingling, itching, 
and tension. The parts are often tender, and may be spon- 
taneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy red, raised 
line. Sometimes recurrent attacks occur at short intervals ; 
generally the disease does not recur. When the scalp is 



204 DISEASES OF THE SKIN. 

invaded, the hair commonly falls during convalescence. 
Sometimes some lesion of the skin may be found as the 
starting-point of the inflammation, or perhaps some lesion 
of the mucous membrane of the nose, mouth, or ear. In 
the recurrent attacks the nose is quite commonly the pec- 
cant member. But in a very large proportion of cases no 
lesion at all will be discoverable. When the disease sub- 
sides the skin desquamates, and returns at last to the 
normal condition. 

Erysipelas occurring upon the trunk or extremities pre- 
sents pretty much the same symptoms as when occurring 
upon the face. 

Etiology. It is now generally accepted that the disease 
is infectious and caused by a specific microorganism that 
was described by Fehleisen. 1 This gains access to the body 
through some lesion of continuity of the skin, however 
minute that may be. As in many of the supposed bacterial 
diseases, so in this one, it is probable that the patient must 
be in the proper condition of health, or rather ill-health, for 
the lodgment of the cocci. It is more frequent in women 
than in men ; and in winter, than in summer. Intemper- 
ance, Bright's disease, parturition, and a lowered state of 
nutrition predispose to it. While the contagiousness of 
surgical erysipelas is well known, and commonly observed, 
it is rare to meet a case of facial erysipelas traceable directly 
to contagion. The possibility of the occurrence of the dis- 
ease without infection by the microorganism may still be 
entertained. It has been thought to arise from taking cold, 
or to begin in some circumscribed purulent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch, ad- 
vancing with more or less steadiness over the surface, the 
process being preceded by a chill and accompanied by 
marked constitutional disturbance, there is little danger of 
mistaking it. It may, however, be mistaken for an erythe- 
matous eczema, an erythema, or urticaria. In eczema the 

1 Deutsche Zeitschrift fur Chirurgie, 1882, xvi. 391. 



ERYSIPELAS. 205 

parts are not so swollen ; the margin of the patch fades into 
the surrounding skin ; the color is not so brilliant ; the sur- 
face is rougher and more scaly ; there is decided itching, 
and a lack of constitutional disturbance of any magnitude. 
Erythema lacks the constitutional symptoms of erysipelas ; 
the redness fades completely away under pressure, without 
leaving a yellowish stain, and springs back promptly when 
the pressure is removed ; it does not creep over the skin ; and 
it is of short duration. In urticaria there will usually be well- 
marked wheals or a history of them ; great itching ; no 
tenderness ; a short course ; a history or evidence of diges- 
tive disturbance ; and an absence of marked constitutional 
disturbance. 

Treatment. The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the fact 
that most cases recover of themselves. There are not a 
few competent observers who are sceptical of the real efficacy 
of any treatment. As the disease tends to lower the vitality 
of the patient we should strive to support his strength by a 
most nutritious diet, and by alcoholic stimulants in adynamic 
cases. The internal medication will be symptomatic to a large 
extent, by means of aconite, quinine, antipyrin, phenacetine, 
and the like. The tincture of the chloride of iron, in twenty 
to sixty minim doses every two or three hours, is regarded 
by many as a specific, and should be given in all but the 
slightest cases. Jaborandi by the mouth, or pilocarpine, 
one-sixth to one-quarter grain hypodermic-ally, have their 
advocates, but must not be thought of in debilitated subjects. 

The local treatment is very important. The lead and 
opium wash is an old remedy and has proved useful in very 
many cases. It may be used hot or cold, whichever is 
most agreeable to the patient. Dry heat will also relieve 
the discomfort of the patient. Resorcin in watery solution 
of 2 or 3 per cent, strength seems at times to cut short the 
disease. Duckworth 1 commends chalk ointment made of 
equal parts of melted lard and chalk, with or without a 
half-drachm of pure carbolic acid to the ounce. This is to 
be smeared on thickly and covered with plain or boric lint. 

1 Practitioner, January, 1887. 



206 DISEASES OF THE SKIN. 

White-lead paint has done well in some hands. White 1 
expects to cure his cases of ordinary facial erysipelas by 
keeping the part constantly covered with cloths saturated 
in the following : 

R . Ac. carbolici, 3 j ; 4 

Alcohol., ") - r\ orn 

Aqua, } aa 0ss 5 250 • M. 

It may be used every alternate hour. Carbolic acid 
may also be used in oil, 10 per cent, strength, and rubbed 
in every hour. Piffard recommends the external use of: 

H . Tinct. belladonna, 1 part. 

Glycerini, 1 " 

Aqua, 8 parts. M. 

Shoemaker is fond of the ointment of the oleate of bis- 
muth. Ichthyol, equal parts with vaseline, or as a paint 
with collodion, may be used. 

The treatment by scarifications about the patch, the in- 
cisions being made diagonally, partly in the sound and partly 
in the diseased skin, and then covered with gauze wet with 
a solution of bichloride of mercury, 1 in 1000, has of late 
been highly praised by many men. This is known as the 
Kraske-Riedel method, and should be always thought of in 
grave cases. Woelfler 2 recommends compression of the 
border line by adhesive plaster strips. 

Prognosis. Many cases of erysipelas recover of them- 
selves in a few days. The prognosis may be said to be 
good in most cases. But even in those that begin as mild 
ones, we should be on the watch for grave symptoms. 
When the scalp is affected the prognosis is more grave than 
when the face alone is the seat of the disease. When the 
patient is the subject of chronic alcoholism, or Bright's dis- 
ease, or is in the puerperal state, the prognosis is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelatous eruption unattended by constitutional 
symptoms. It is an infectious disease originating in a wound 

1 Trans. Amer. Derm. Assoc, 1890. 

2 Wiener klin. Wochenschr., 1889, Nos. 23 and 25. 



ERYTHEMA. 



207 



from contact with some dead, putrefying animal substance, and 
chiefly affecting cooks, butchers, fishmongers, and the like. 
It occurs mostly on the fingers, and spreads from the point 
of inoculation as a dark-red, often livid swelling with a 
sharp border. As it travels over the surface the central 
portion undergoes involution, and thus circles may be formed. 
It stops spontaneously after one to three weeks' duration. 
A salicylic acid or other antiseptic ointment may be used in 
treatment. 

Erythanthema (E 2 r-i 2 -tha 2 n r the 2 ma 3 ) is a term employed 
by Auspitz to designate a class of cutaneous efflorescences 
which have in common a basis of erythema. (Foster.) 

Erythema (E 2 r-i 2 -the r ma 3 ). Synonyms : Dermatitis ery- 
thematosa, Erysipelas suffusum ; (Fr.) Erytheme, Dartre 
erythemo'ide; (Ger.) Erythem, Hautrothe ; Rose rash. 

An inflammatory hyperemia of the skin attended with 
redness of the surface, and usually only slight or imper- 
septible exudation, and with little or no disturbance of the 
epidermis. (Foster.) 

There are many forms of erythema, but they may all be 
classed under one of two main varieties, namely : Erythema 
hyperaemicum, and Erythema exudativum. I shall follow 
Crocker's classification, as it is a practical one. It is a 
question whether erythema should be regarded as a disease 
or a symptom. 



f i. 



Erythema - 



E. hypersemicum \ 



I 



Due to external 
causes 



Due to internal 
causes 



E. exudativum 



E. multiforme 
E. seu Herpes iris 
E. nodosum 
k E. gangrenosum 



f E. simplex. 

J E. pernio. 

-J E. intertrigo. 

j E. lreve. 

[ E. paratrimma. 

{ E. fugax. 

j E. urticans. 

I E. roseola. 

^ E. scarlatiniforine. 



Symptoms. Erythema Hypercemicwm. This form of 
erythema is characterized by simple redness without swell- 
ing, and usually is not followed by desquamation. This 



208 DISEASES OF THE SKIN 

shows that it is due simply to a localized hyperemia with- 
out inflammation. It is always of short duration. The 
redness disappears under pressure, but springs back again 
as soon as the pressure is removed. It occurs both in cir- 
cumscribed patches of large or small size, or diffused over 
large areas. Subjective symptoms are often hardly notice- 
able. There may be some burning and tenderness, but 
there is never decided itching. The patient may rub his 
skin gently, but never scratches violently. There may be 
slight constitutional symptoms with fever of mild grade, 
or some digestive disturbance, but these are not properly 
symptoms of the erythema, but rather of the underlying 
disease of which the eruption is but an accidental expres- 
sion. For instance, two people may eat the same thing. 
In both there may be digestive disturbances. But one will 
have an erythema and the other will escape. 

Etiology. This form of erythema may arise either from 
external or internal causes. Those arising from external 
causes are localized, while those due to internal causes are 
general. Both are angioneuroses, and predisposed to by an 
inborn susceptibility, that is idiosyncrasy, of the patient. 

In the first group we have Erythema simplex, due to 
the rubbing of the clothing, the effect of heat or cold, as of 
the sun or wind, and of various vegetable or chemical irri- 
tants. Many of these simple erythemas we have already 
described under the caption of Dermatitis venenata, which 
see. They are usually localized, and for treatment require 
only the removal of the irritating cause, and the application 
of a simple dusting-powder or ointment. 

Erythema Pernio has been described under Dermatitis 
calorica, which see. 

Erythema Intertrigo, or simply Intertrigo, is an erythema 
occurring between two folds of skin. It is most commonly 
seen in fat infants in the folds of the skin of the neck and 
joints. It is also encountered in adults who are corpulent, and 
is often a very annoying trouble to women, where it fre- 
quently occurs underneath the hanging breasts. It also 
occurs in adults between the scrotum and inside of the 
thighs, under the prepuce, in the furrows alongside of the 



ERYTHEMA. 209 

vulva, in the joints, and all other skin creases. It is caused 
by the friction in walking and favored by heat and moisture. 
It is therefore more common in warm weather. If not at 
once and properly attended to, the decomposition of the 
sweat and sebaceous matters will aggravate it ; and the 
irritation being continued, an eczema will start up. It is, 
in infants, very common about the inside of the thighs, 
where the wet napkins cause and aggravate it. It is very 
often accompanied by a disagreeable, cheesy odor, and, 
contrary to what obtains in other erythemas, there is exuda- 
tion upon the skin in some cases. 

Diagnosis. The diagnosis from eczema is very often 
difficult. Indeed, they run into each other so imperceptibly 
at times that it is difficult to tell where erythema leaves off 
and eczema begins. But eczema itches more than erythema, 
it tends to spread further beyond the affected part, and its 
exudation is not only sticky, but also stains and stiffens 
linen. The location in the skin-folds should suggest an 
erythema. Happily, the differentiation is a matter of no 
great importance as the same treatment is applicable to 
both. 

In infantile syphilis we frequently have an eruption upon 
the buttocks and inside of the thighs that bears a decided 
resemblance to intertrigo. Here a correct diagnosis is of 
great importance. In syphilis the redness commonly ex- 
tends down the whole inside of the legs to the feet and 
soles, it is of a darker color, and there will be other symp- 
toms of the disease, such as snuffles, large or small papules 
to the outside of the red patch, mucous patches, and the 
like. In infants' asylums, where a great number of debili- 
tated as well as syphilitic children are received, opportuni- 
ties for the differentiation between syphilis and intertrigo 
frequently occur. 

Treatment. The treatment of intertrigo is simple. The 
opposing surfaces of skin must be separated by pieces of 
lint, the furrows must be kept perfectly clean, and dusting- 
powders of starch, talc, lycopodium, and the like must be 
freely used. To these powders oxide of zinc, boric acid, or 
Other astringents may be added. Hardaway recommends : 



210 DISEASES OF THE SKIN. 

R. Thymol, _ gr. j. 

Pulv. zinci oleat., ^j. M. 

As a rule, powders answer better than ointments, though 
Lassar's paste, as given under Eczema, may be used. The 
treatment of intertrigo in infants is to be managed in the 
same way as eczema. (See under Eczema infantile.) 

Erythema Lceve is an obsolete term, which was employed 
to indicate the redness seen on oedematous limbs. Let it 
rest. 

Erythema Paratrimma belongs to the same category, only 
here it was the redness over bony prominences, as that pre- 
ceding a bed-sore. 

We have now to consider the second group of erythema 
hypersemicum, those which are due to internal causes. Here 
might be placed all the erythemata, as well as the drug 
eruptions. But the first of these belong to the domain of 
general medicine, and the last will be found under Derma- 
titis medicamentosa. 

Erythema Fugax is, as its name indicates, a fugitive ery- 
thema, as it were a prolonged blush. It is seen most often 
in children with some digestive disturbance, and its chosen 
location is the face. It lasts for a few moments or hours, 
and is seldom seen by the physician, although he will be 
told, not infrequently, by patients that they are annoyed 
by a flushing of the face after eating, exposure to cold, 
or mental emotion. It is to be managed like Urticaria, 
which see. 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Roseola, or simply roseola. While children 
are more subject to this form of erythema than adults are, 
it may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in most, 
if not all, cases to digestive disorders or other constitutional 
disturbance, it is usually ushered in with rise of tempera- 
ture, which may be pretty sharp, 103° or 104° F., furred 
tongue, restlessness, and the like. Soon the eruption ap- 
pears, which may be a blotchy redness, or in faintly marked 
papules, or in rings, or gyrate figures. The eruption lasts 



ERYTHEMA. 211 

a few hours only, or, coming and going in different places, 
it may be prolonged for a few days. Besides digestive dis- 
orders, gout, changes of temperature, and the seasons of 
spring and autumn have been assigned as causes. 

Diagnosis. In itself it is a matter of little moment, but 
as it resembles scarlet fever, rotheln, and measles, its diag- 
nosis is important. It differs from scarlatina in not having 
such severe constitutional symptoms ; in an absence of the 
strawberry tongue, swollen, reddened fauces, and enlarged 
glands; in the rash coming out all over the body without 
following any regular course of development from the neck 
downward ; in the eruption being blotchy or papular, and 
not a diffused redness. After watching the case for a day 
the diagnosis will be evident by the clearing away of the 
disease wholly or partially. It differs from measles in an 
entire absence of catarrhal symptoms, and in its eruption 
not being crescentic, as well as in the irregularity of its 
course, the mildness of its symptoms, and the brightness of 
its color. It bears most resemblance to rotheln, and prob- 
ably the two are often confounded. If there is a clear his- 
tory of contagion, or more than one member of the family 
affected at the same time, the diagnosis of rotheln is at once 
established. Rotheln is more pronounced on the extremi- 
ties, and the lesions are of a more stable character. In case 
of doubt as to diagnosis of roseola the patient should be 
regarded as having a contagious disease, isolated and care- 
fully watched. 

Treatment. Little need be done for the patient but to 
give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the first 
few days of life, and is thought to be due to the influence 
of external and unusual irritants acting upon the tender 
skin of a newborn child. " The eruption consists of very 
minute red papules, seated upon a hypersemic base, which 
can be made to lose their color upon pressure. The lesions 
are most pronounced upon the back and breast, and fade away 
in a few days with slight desquamation of the most con- 
gested spots. The mucous membranes are unaffected, and 
there is no evidence of systemic reaction," (Hardaway.) 



212 DISEASES OF THE SKIN. 

Erythema Scarlatiniforme. A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 
frequently mentioned in the section on Dermatitis medica- 
mentosa. The French authors describe a scarlatiniform 
erythema under the name of Erythemes scarlatiniformes 
recidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first described 
by Fereol in 1876 at the Societe Medicale de Hopitaux de 
Paris. The disease is marked by redness, desquamation, 
and relapses. Its outbreak may or may not be preceded 
for one or two days by malaise and slight febrile movement. 
It begins on the trunk and invades the whole surface in a 
few hours or in two days. It is a diffused, uniform, in- 
tense, scarlatinal, or sombre-red eruption. There may be 
slight differences in the shade, or the redness maybe punctate, 
or some pin-head vesicles may develop upon it. Sometimes 
the eruption is limited to a certain portion of the body ; 
sometimes the eruption is general, but not universal, normal 
islands of skin being found in the general redness. It 
comes out in patches that run together. There is generally 
redness of the mucous membrane of the mouth and fauces. 
There is no thickening of the skin nor infiltration of mucous 
membranes. The skin burns, and there may be slight itch- 
ing. Exfoliation of the skin begins almost as soon as the 
eruption is out, commencing at the point of invasion. The 
desquamation is general, and may be furfuraceous, or abun- 
dant and in large plaques. Upon the scalp it is furfuraceous. 
The whole process may take but one or two days, or it may 
be prolonged for a month or six weeks. The hair and nails 
may be shed. The tongue is furred and may desquamate, 
but never presents the papillae of scarlatina. After the 
beginning of the attack there is usually no fever, and the 
appetite is preserved. There may be albuminuria during 
the attack. The relapses, which are apt to occur after in- 
tervals of days, months, or years, are less pronounced, and 
the patient's health is good in the interim. 

Etiology. The cause of the disease is very often ob- 

1 Annal. de Derm, et de Syph., 1890, i. 1. 



ERYTHEMA EXUDATIVUM. 213 

scure. The first attack has been observed to follow ex- 
posure to cold, the application of mercurial ointment, or 
the action of other irritant. But it is difficult to explain 
why from such causes relapses should occur. Besnier 
thinks that in some cases the cause is a poison developed 
within the individual. In this way he would explain some 
of the erythemas developing during an acute urethritis, 
which some observers claim may arise quite independent of 
the taking of copaiba. Scarlatiniform erythemas occur 
occasionally in septicemic conditions, in typhus fever, in 
malaria of children, in sewer-gas poisoning, and in various 
other conditions. 

Diagnosis. Brocq considers scarlatiniform erythema as 
one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
having no permanent effect upon the health, by running 
a shorter course, and by the skin not being dry, contracted, 
and shrivelled. It differs from scarlatina in the mildness 
of its constitutional symptoms ; by the course of the erup- 
tion ; by the absence of tumefaction of the fauces, and the 
strawberry tongue ; by the early desquamation ; by not 
being contagious ; and by its tendency to relapse. If there is 
any doubt as to the diagnosis the patient should be isolated. 
It differs from erythematous eczema in an entire absence 
both of thickening and moisture; in being less itchy; and 
in its rapid course. 

Treatment. The treatment is purely symptomatic. 

Erythema Exudativum, the second variety of erythema, 
differs from erythema hypersemicum in the presence of an 
exudation into, not on, the skin so that the patches are 
raised above the level of the skin ; and in never involving 
the whole surface, but always occurring in circumscribed 
patches. The two varieties are alike in that the redness 
disappears under pressure to return at once when the pres- 
sure is removed. It is probable that erythema nodosum is 
really but a part of erythema multiforme, as the two forms 
may be present at one time. But it is usually described 
apart, and although this may not be strictly accurate, it is 
convenient. 



214 DISEASES OF THE SKIN. 

Erythema (Exudativum) Multiforme, as its name indi- 
cates, is very multiform in its efflorescences. For a day or 
a few days before they appear there is some constitutional 
disturbance. This may be nothing more than slight malaise, 
the patient not feeling as well as usual. From these in- 
definite symptoms, there are all grades up to fever of 104° F., 
headache, gastric disturbances, and severe muscular and 
articular pains like rheumatism. According to Besnier and 
Doyon an erythema of the pharynx, or a pharyngitis, 
laryngitis, or bronchitis, often precede or accompany the 
outbreak of the eruption upon the skin. The eruption is 
most constantly seen upon the backs of the hands and feet, 
and here it commonly begins, though this is denied by 
PolotebnofF, to whom we are indebted for a most exhaustive 
and able study of erythema. 1 It also appears on the trunk 
and extremities more or less generally, coming out in crops, 
and preserving a rough symmetry. Sometimes it may re- 
main confined to a single region, as the backs of the hands. 
Sometimes it occurs on the mucous membranes, as of the 
mouth and eyes. It is usually most marked and abundant 
about the joints should they have exhibited rheumatic pains. 
It is rare not to find lesions upon the backs of the hands. 
With the appearance of the eruption there is a subsidence 
of the constitutional symptoms, though in many cases the 
patients are more or less definitely ill during the whole 
course of the disease. 

The eruption commences as a group of deep-red papules, 
from pin-head to pea size, conical or rounded, and this is 
called Erythema papulatum. The eruption may continue 
as such ; or the papules may coalesce and form elevated 
patches, sharply marked against the sound skin ; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the centre, and ring-shaped, the periphery 
being deep-red while the centre is purplish. This is called 
erythema circinatum or annulare. Sometimes it happens 
that the ring still enlarges by successive exudations, and 
then we will have ring within ring, the outer one pink, the 

1 Zur Lelire von den Erytlienien. Hamburg, 1887. 



EKYTHEMA EXUDATIVUM. 215 

next red, the next purplish, thus forming an iris-like play of 
colors that has been termed erythema iris. Two rings near 
each other and enlarging will after a time meet at the 
peripheries, the points of contact will melt into each other 
and disappear, and then we will have a large patch with a 
figure-of-eight or scalloped, raised border and a flattened 
centre. This is called erythema marginatum. It may 
travel over a large part of the trunk or the circumference 
of a limb, leaving a fawn-colored pigmentation, which soon 
fades. Or two rings meet, and each breaks, and only a 
gyrate line is formed, to which the name of erythema gyratum 
is applied. Sometimes, though rarely, the exudation is so 
abundant that the epidermis is raised in the form of vesicles 
or bullae. This is erythema bullosum. Hemorrhage may 
take place into the bullae. 

It is uncommon to find all these forms present at the 
same time, nor must it be understood that one form neces- 
sarily evolves into the other. The evolution may stop at 
any point. Most often this is at the papular stage. Never- 
theless, more than one form is usually to be seen, so that the 
term multiform is merited. Crocker says that in children 
multiformity is less the rule, the constitutional symp- 
toms are more pronounced, and if vesiculation occur, the 
vesicles are more prone to become purulent and leave 
scars. 

The duration of the disease is from two to four weeks, 
but may be extended by a succession of outbreaks for 
months or years. The eruption is attended with burning, 
rather than itching, and sometimes by a feeling of tension. 
Slight pigmentation may be left, but it is transitory. Des- 
quamation may follow the eruption, but is not common. 
In some patients there is a decided tendency to relapse at 
irregular intervals for years. In Prof. Geo. Henry Fox's 
service at the Vanderbilt Clinic I have seen a boy with a 
relapsing bullous erythema of the face and ears that had 
appeared at intervals during ten years. The bullae were of 
large size, fully distended, and of irregular shape. They 
left depressed, pigmented cicatrices in some places. Similar 
cases have been reported by others, as, for instance, by 
Hardaway, who saw one case with relapses for four years ; 



216 DISEASES OF THE SKIN. 

and T. C. Fox, who saw two cases with a duratian of sixteen 
years in each case. 

As complications of erythema multiforme, and especially 
of erythema nodosum, have been reported endo- and peri- 
carditis, meningitis, pleurisy, pneumonia, and the like, but 
it is better to regard these diseases not as complicating the 
erythema, but as the primary diseases of which the ery- 
thema is a phenomenon. 

Erythema Iris. This very rare disease was formerly re- 
garded as a herpes, and is described in most text-books as 
herpes iris. Its other synonyms are hydroa, herpes circin- 
atus, and hydroa vesiculeux. The opinion has been gain- 
ing ground that it is only a form of erythema, and it is 
placed in the group of erythema multiforme by Crocker 
and by Hardaway. It is seen sometimes along with other 
manifestations of erythema multiforme, or with herpes, 
though it usually occurs alone. It is located most often 
upon the backs of the hands and feet, and upon the arms 
and legs, but it may occur anywhere upon the skin as well 
as the mucous membranes. I have seen one case upon the 
buttocks as well as upon the elbows. According to Crocker 
there are two varieties of the disease, one with a central 
vesicle or a purplish depression surrounded by one or more 
whitish rings slightly raised up by effused fluid ; the other 
with a central bulla with one or more rings of more or less 
discrete vesicles round it. Of these two the first is the 
most frequent. 

The first variety begins as a small erythematous papule 
upon which a pinhead- sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 
preserves a red areola. When about a quarter of an inch in 
diameter the fluid is absorbed in the centre, leaving a pur- 
plish depression ; or only a ring of absorption occurs, so that 
there will remain a vesicle in the centre with a purplish 
zone about it, and then a raised white ring, and around 
all a narrow, pink areola. This play of colors gives the 
name of iris. The patch may reach the diameter of half 
an inch, and then undergo involution ; or several patches 
may unite and form patches of one inch or more in diam- 



ERYTHEMA EXUDATIVUM. 217 

meter, and hemorrhage may take place into the bullae that 
may form. 

In the second variety, which is the hydroa vesiculeux 
bulleux of Bazin, round a central bulla a ring of split-pea- 
sized vesicles forms, the vesicles being either discrete or 
touching. A second or a third ring of vesicles may form 
outside of these, the skin between them being of a purplish 
tint. The bullae and vesicles may leave scars. Crusting also 
takes place from the breaking or drying of the vesicles. 

The lesions of both varieties are more or less symmetri- 
cal, though a patch may develop on one side several days 
before the other. The duration is from three to four 
weeks or longer. Relapses are common. Burning is usually 
pronounced, and there may be some itching. From this 
description it will be seen that the so-called herpes iris is 
really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and Erythema noueux (Fr.), is more common than erythema 
iris, but not nearly so common as erythema multiforme. 
It is, probably, really but a variety of erythema multi- 
forme, as it may occur as a part of that disorder. In the 
vast majority of cases it occurs alone. Its prodromal 
symptoms are substantially the same as those of erythema 
multiforme, but its rheumatic pains are more pronounced 
and always present. There is also tenderness and pain 
over the tibiae. After a few days of prodromata, round 
or, more often, oval, bright or rosy red swellings appear 
over the tibiae, with their long axis vertical. These are from 
nut to egg-sized ; raised ; their borders merge gradually into 
the surrounding skin ; they are painful and often ex- 
quisitely tender ; firm at first but may be semi-fluctuating 
afterward ; and their color darkens to a dark red, then 
purple, and in undergoing absorption they present the ap- 
pearance of a black- and-blue spot from a bruise. The color 
at first disappears under pressure, to spring back when the 
pressure is removed. The changes of color subsequently 
seen are due to the gradual absorption of the coloring mat- 
ters of the blood deposited in the tissues. There are not 
usually more than a dozen lesions, generally less. They 

10 



218 DISEASES OF THE SKIN. 

are most frequently located over the tibiae, but may occur 
as well upon the arms, scapulae, thighs, and mucous mem- 
branes. They are roughly symmetrical. The duration of 
the disease is, like that of other erythemas, two to four 
weeks. 

Etiology. The causes of erythema exudativum are not 
fully determined. It occurs more commonly in women than 
in men, and in young adults rather than in old people. 
Erythema nodosum is said to be most frequent in children. 
It is most frequent in the spring and autumn, seasons in 
which dampness and cold winds prevail, and sudden changes 
of temperature are common. The papular erythema is very 
often seen in recently arrived immigrants. Rheumatism 
has a well-marked causal relation to erythema nodosum, 
and, it may be, to the other forms. Syphilis seems to be 
an etiological factor of some weight in the production of 
erythema nodosum. Some years ago I saw in the service 
of Professor E. B. Bronson in the New York Polyclinic a 
well-marked instance of this in the course of recent syphilis 
in a woman. Many cases seem to be due to systemic poison- 
ing either by some infectious disease or by auto-infection. 
It is seen with cholera, influenza, and the exanthemata; 
with indigestion, pregnancy, parturition, menstrual disturb- 
ances, kidney diseases, and various other internal or systemic 
disorders. Sometimes the disease seems to be a pure angio- 
neurosis. Cases of erythema multiforme recurring with 
recurring attacks of gonorrhoea have been reported. These 
appear as reflex angioneuroses without the ingestion of 
balsamics in the treatment of the urethritis. Cases of 
erythema multiforme not infrequently follow the ingestion 
of drugs ; at least they are almost identical with it in 
appearance. Sometimes, according to PolotabnofF, it seems 
to be an abortive form of prevailing epidemics. Cases 
certainly should be watched carefully in connection with 
other symptoms, as they may be but part of the prodromata 
of some grave disorder. I have seen one case in which a 
well-marked erythema multiforme preceded for about ten 
days the outbreak of typhoid fever ; the erythema then 
disappearing and the characteristic typhoid eruption coming 



ERYTHEMA EXUDATIVUM. 219 

in due course. Many of the subjects of erythema are de- 
bilitated. Individual predisposition probably plays an im- 
portant role in the etiology of some cases, especially in the 
relapsing ones. 

Pathology. All forms of the disease show not only 
hyperemia, but also inflammatory effusion both of fluid and 
leucocytes. Upon the amount of this fluid depends the 
character of the lesion. If small in amount it will simply 
push up the epidermis into a papule or tubercle ; if of 
larger amount we will have vesicles and bullae. There is 
also an escape of the coloring matter of the blood into the 
tissues. (Crocker.) 

Diagnosis. If the characteristics of erythema multi- 
forme are borne in mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright 
or rosy-red lesions, located by preference upon the backs of 
the hands and feet ; and the color that fades away entirely 
under pressure to return again when pressure is removed, 
and in disappearing leaves stains. It most resembles 
urticaria, but differs from it in having more stable lesions 
of more varied shape ; in absence of wheals ; in occur- 
ring particularly on the backs of the hands and feet ; and 
in burning rather than itching. The papular form dif- 
fers from jiapular eczema in its chosen locations ; in its 
burning rather than itching ; in its papules being larger 
and never developing vesicles nor forming patches ; in an 
absence of thickening of the skin ; in disappearing com- 
pletely under pressure ; in tending to get well without 
treatment ; and in leaving stains. The nodes of erythema 
nodosum differ from those of sy2)liilis in occurring suddenly 
and not gradually. In syphilis the redness does not occur 
until after the node has existed for some time, and the 
nodes are not tender nor developed symmetrically. More- 
over there would be other evidences of syphilis. 

Treatment. There is nothing that will lessen the dura- 
tion of the disease, though Villemin 1 maintains that iodide 
of potassium, in doses of at least thirty grains a day, is 

1 Gaz. hebdom., May 24, 1886. 



220 DISEASES OF THE SKIN. 

almost a specific, and will abort relapses. The experience 
of Besnier and others has not been in accord with that of 
Villemin. The treatment is mainly symptomatic, and di- 
rected to relieving the constipation, regulating the diet, aiding 
digestion, ameliorating rheumatism, or toning up the system. 
In obstinate cases the patient had best be kept in bed. 
Locally any alkaline lotion will afford relief, such as 



Or, 



R. Pulv. calamin. prep., ^ij; 4 

Zinci oxid., 3 ss ; 3 

Liq calcis, % ij ; 100 



M. 



Be. Liquor plunibi subacetat is, Tltxv ; 3| 

Aqua?, 3j ; 100| M. 



Or, lead and opium wash. 

Sometimes a simple dusting-powder will do as well. In 
erythema nodosum the patient should be kept in bed, and 
often the lotion is more agreeable to the patient when used 
warm. Salicylic acid or salicylate of soda internally may 
afford relief to the sometimes intense pains. Regulation 
and simplification of the diet, and the administration of 
diuretics or tonics, according to the nature of the case, will 
do good in the disease as seen in immigrants. 

Erythema Centrifuge. See Lupus erythematosus. 

Erythema Gangrenosum, though described as a disease 
is probably always a feigned eruption, and needs no de- 
scription here. 

Erythema Mamelonne. See Erythema roseola. 

Erythema Papuleux Desquamatif (Vidal). See Pityriasis 
maculata et circinata. 

Erythema Noueux. See Erythema nodosum. 

Erythrasma (E" 2 r-i 2 -thra 2 z-ma 3 ). A contagious parasitic 
disease of the skin ? occurring especially in the groins and 
axillae in the form of sharply defined, brownish-red, desqua- 
mating patches, bordered by a fringe of broken and partly 
detached epidermis. (Foster.) 

This affection of the skin is very rarely seen in this coun- 
try. This may be because it gives no trouble to the patient, 
and therefore he does not apply to the physician. It begins 



ERYTHRASMA. 221 

as a little yellowish point that soon becomes a lentil-sizecl 
macule, and grows into a patch the size of a silver dollar or 
the hand. Several patches join together so that large sur- 
faces may be involved. The patches are oval or disc-shaped. 
They are located in the situations where intertrigo is liable 
to occur, such as the axillae, groins, and where the scrotum 
comes in contact with the thighs. The latter situation is 
declared by Besnier to be nearly always the original site of 
the disease. From these favorite locations the disease may 
spread to the chest, abdomen, or thighs. Besnier 1 met 
with a case involving the thigh down to the knee. The color 
of the patches is orange, red, yelloAvish, or brownish, or, in 
the folds of the skin, pale red. Their outline is sometimes 
marked by a raising of the epidermis. Their surface is 
dull-looking, and feels less smooth than normal. They are 
quite tenacious, cannot be readily rubbed off, and show little 
tendency to spontaneous recovery. There may be slight 
itching, and a very little delicate scaling. 

Etiology. The disease occurs most often in men, and 
never in children. It is due to a parasite called the micro- 
sporon minutissimum which is described by Balzer 2 as con- 
sisting of long, wavy mycelia, that are rarely branched; 
and of very fine spores. High powers of the microscope 
are necessary to see them. They are located exclusively in 
the corneous layer of the skin. He regards them as a 
common form of parasite that produces the disease only in 
some people on account of the peculiar fermentation of 
their skin secretions. 

Diagnosis. The disease resembles both chromophytosis, 
eczema marginatum, and chloasma. It differs from 
chromophytosis by the darkness of its color ; by the ab- 
sence of distinct rather large scales that can be lifted by the 
nail; by its location, sparing the trunk, except by exten- 
sion ; and by the character of the microscopical appearances. 
From eczema marginatum it is distinguished by an absence 
of all inflammatory symptoms, by not being more pro- 

1 Journ. de Med. et de Chirurg. prat., 1883, liv. 351. 

2 Annal. Derm, et Syph., 1884, v. 597. 



222 DISEASES OF THE SKIN. 

nounced at the periphery than at the centre, and by the 
microscopical appearances. From chloasma it differs by 
being a parasitic and not a pigmentary disease, and by the 
change it causes in the feel and texture of the skin, and by 
the effect of treatment. 

Treatment. It is curable by the same means as is 
chromophytosis, namely by the tincture of iodine ; pyro- 
gallol ; chrysarobin ; bichloride of mercury ; or sulphur. 
It is more obstinate than is chromophytosis, and quite as 
prone to relapse unless thoroughly eradicated. 

Erythromelalgia (E 2 r / i 2 -thro-me 2 l-a 2 l / gi 2 -a 3 ) is a nervous 
disease characterized by the appearance of a persistent patcli 
of congestion, often on the sole of the foot, attended with 
swelling and pain. (Foster.) 

Esthiomene (E 2 s-te-o-me 2 n). This is a disease of the 
ano-vulvar region that was described by Huguier, 1 and about 
which there is a good deal of uncertainty. It has been 
variously considered as a form of lupus, syphilis, elephantia- 
sis, and epithelioma. " It is characterized by a leaden or 
violaceous hue of the parts, and their simultaneous altera- 
tion of shape, induration, thickening, ulceration, destruc- 
tion, hypertrophy, and infiltration, so that the orifices and 
canals of the vulvo-anal region may be at the same time 
ulcerated, enlarged, and constricted, and its grooves and 
cutaneous and mucous folds exaggerated, thickened, and the 
seat of more or less extensive and deep ulcerations and 
cicatrices; without pain, without directly threatening life, 
and for a long time without affecting the constitution. 
(Foster.) 

Exanthematous Fevers. These concern us as dermatolo- 
gists only in the matter of diagnosis. They are chiefly 
liable to be mistaken for different forms of erythema hyper- 
semicum, and their diiferentiation from these has been already 
considered. (See Erythema.) Besides this, measles must 
be differentiated from the erythematous syphilide ; variola 
from papulo-pustular syphilide and acne; scarlatina from 

1 Mem. de l'Acad. de Med. I860, p. 507. 



favus. 223 

erythematous eczema ; and varicella from vesicular eczema 
and impetigo contagiosa. Consideration of the constitu- 
tional symptoms and the course of the disease in question 
should leave little doubt as to diagnosis, and in any event 
watching the case for a day or so will decide it positively. 
See also Morbilli, Scarlatina, Rotheln, etc. 

Farcy. See Equinia. 

Favus (Fa 3/ vu 3 s). Synonyms : Porrigo lupinosa, seu 
favosa, seu lavalis, seu scutulata ; Porrigophyta ; Tinea 
favosa, seu vera, seu ficosa, seu lupinosa, seu maligna ; Tri- 
chomykosis or Dermatomycosis favosa ; (Fr.) Teigne faveuse, 
teigne du pauvre ; (Ger.) Erbgrind ; Crusted or honey-comb 
ringworm, Scall head, True porrigo. 

A contagious vegetable parasitic disease due to the 
Acliorion Schoenleinii, and characterized by the presence of 
discrete or confluent, circular, pale sulphur-yellow cupped 
crusts, or by asbestos-like masses of grayish friable crusts ; 
by loss of hair producing irregularly-shaped, disseminated, 
red, bald patches ; by permanent atrophy of the scalp ; and 
by running a chronic course. 

Symptoms. Favus affects both the scalp and the non- 
hairy skin as well as the nails and mucous membrane. We 
will first describe it as it affects the scalp. It begins either 
as one or more scaly erythematous spots ; or as minute yel- 
lowish puncta ; or as a group of vesicles smaller than those 
met with in ringworm. These develop into small sulphur- 
yellow cupped crusts about the hairs. When the case is 
seen by the physician the early stage is usually passed, and 
he will find that the hair is dry and lustreless, and has fallen 
out in places, leaving irregularly- shaped bald patches, of all 
sizes, and of pronounced red color. Upon both the bald 
patches and the parts still covered with hair the sulphur- 
yellow cup or saucer-shaped crusts will be found, with raised 
or rounded edges, and with one or several hairs growing out 
of the middle of them. There will be also more or less 
scaling, and, if the disease be of some age, thick mortar-like 
crusts of grayish color. In some cases when first seen it 
may be impossible to find the characteristic crusts, scutula 



224 DISEASES OF THE SKIN 

Fig. 18. 




Case of favus of hand showing scutula. Side view. 



Fig. 19. 




Favus of hand, front view. 



favus. 225 

as they are called, they being obscured by the mortar-like 
masses. In some cases the scutula are wanting;. If we 
approach near enough to the patient we will appreciate a 
peculiar odor variously described as that of mice, straw, or 
of a menagerie. 

The crusts, scutula, or favi are situated about the hair 
follicles. They are from pin-head to split-pea size, accord- 
ing to age. At first they are covered with a thin layer of 
epidermis, but later the edges are free. When they are 
picked off they leave a moist depression which soon fills up, 
or a pustule, or an atrophied spot. The color is pale or 
sulphur-yellow, or, if of long standing, it may be a dirty or 
greenish-yellow. The crusts are discrete and disseminated 
or grouped ; sometimes they coalesce ; they are firm to the 
touch, and when crushed between the fingers impart a feeling 
of crumbling like mortar. There is a slight zone of redness 
about them. Though they may not be seen at the first 
examination, if the scalp is cleaned off and left to itself they 
will form in the course of two or three weeks. The bald- 
ness is rarely in well-defined shapes. The patches may be 
few in number, or so numerous that the hair occurs only in 
islands. At first their color is inflammatorv red ; later 
they become white and atrophic in appearance. The bald- 
ness is permanent. The hair is dry from the first ; later it 
becomes brittle and split longitudinally; but it is never so 
easily broken as in ringworm, and can easily be pulled out 
with its roots. There is itching of the scalp. That is the 
only subjective symptom. Pustulation does not belong to 
the disease, but may be an accidental complication. Other 
complications that may arise are pediculosis, eczema, and 
enlargement of the cervical glands. 

Occurring upon non-hairy parts it undergoes materially 
the same development and forms the characteristic cups. 
Sometimes it will take the circular form of a ringworm with 
the development of vesicles, and resemble it very closely 
only that the cups will be sure to develop somewhere. (Figs. 
18 and 19.) The scutula develop around the lanugo hairs. 
On the non-hairy parts the disease is easier of cure than on 
the scalp, and is not so apt to leave scars. In a single case ? 

10* 



226 



DISEASES OF THE SKIN". 



that of Kaposi, the favic fungus was found implanted upon 
the mucous membrane of the stomach. The nails may be 
affected, either in the form of onychitis beginning at the 
side of the nail hardly distinguishable from the same dis- 
ease developed from common causes ; or in having a scutu- 
lum develop in the nail-bed and showing through the nail. 
This is rare. The occurrence of favus upon the head will 
give a clue to the origin of the onychitis. 

Etiology. The disease is due to the implanation and 
growth of the Aclwrion Schoenleinii primarily in the scalp 
and secondarily in the hair. It is contagious, but not so 
much so as is ringworm. It used to be rare in this city but 
on account of its being constantly imported from Europe 
the disease is on the increase, and cases are beginning to 
occur in native Americans. Its course is very chronic, and 
it shows less tendency than ringworm does to spontaneous 
recovery about the time of puberty, though children are 
more commonly affected than are adults. It has been 
asserted that the strumous diathesis predisposes to favus, 
but this is doubtful. Like all other parasites it requires a 
certain soil upon which to grow, and does not affect all skins. 
It is a disease common in mice, and may occur in rabbits, 
dogs, cats, and fowls, and be a source of contagion for the 
human race. 

Fig. 20. 




V 

Achorion Schoenleinii. (After Kaposi.) 

Pathology. The cups are composed almost wholly of 
the fungus, which consists of flat, narrow, branching, and 



FAVUS. 



227 



inosculating mycelial threads -g-J-^-th of an inch in diameter, 
and of pale gray color; and of small spores of round, oval, 
flask, or dumb-bell shape, and of a pale greenish color. 
(Figs. 20, 21.) The spores gain access to the skin by the 



Fig. 21. 




Achorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 

orifices of the hair follicles, and, after remaining there undis- 
turbed, begin to grow in the upper part of the hair sac, and 
between the superficial layers of the epidermis, and subse- 
quently invade the hair, growing in its cortical substance. 
The cup may be formed either by the sinking in of the more 



228 DISEASES OF THE SKIN. 

central portion of the mass, or on account of the central 
portion being attached to the hair so firmly that it cannot 
so readily give way and bow out under the pressure of the 
growing fungus as do the parts further away from the hair. 
The atrophy of the skin is largely due to the pressure of the 
growing fungus, which is powerful enough to destroy the 
cranial bones of mice ; and in part to the inflammation of 
the skin produced by the presence of the fungus. 

The question of the unity or non-unity of the fungus of 
favus is still unsettled. Several fungi, Quincke says three, 
seem capable of producing the clinical picture of the dis- 
ease. Other competent bacteriologists hold that the appa- 
rently diverse fungi are either different stages of develop- 
ment of the same fungus or due to different culture media. 
It is distinct from the trichophyton fungus. 

Diagnosis. Most cases of favus are easy of diagnosis : 
the sulphur-yellow cupped crusts ; the asbestos-like grayish 
masses ; the red, atrophic bald spots ; and the peculiar odor 
being so well marked. Ringworm has none of these fea- 
tures. Moreover, it occurs in the form of circular, circum- 
scribed, only partially bald patches covered with grayish 
scales in moderate amount; has characteristic nibbled-off 
"stumps" of hair; and under the microscope we find the 
spores less abundant, smaller, and more uniformly round 
than in favus. It must be confessed, however, that without 
the clinical features of one or the other disease, none but a 
most expert microscopist could make the diagnosis by the 
microscope alone. In eczema baldness is very rare, and we 
will usually find a characteristic patch of the disease behind 
the ear ; its crusts are greenish and tenacious, not gray and 
friable ; the hair is matted by the sticky exudation ; and if 
discrete impetigo lesions are present they will contain pus, 
and not be solid like the favus crust. Leaving the scalp 
alone for a time will decide the matter, as scutula will be 
sure to form if the disease is favus. Seborrhoea causes a 
general thinning of the hair, the scalp is not atrophic, there 
are no scutula, and no achorion in the hair and scalp. Lupus 
erythematosus resembles favus only in producing atrophic red 
spots. There will usually be patches of the disease else- 



favus. 229 

where, and its whole course is different. Psoriasis does 
not cause atrophic bald spots, and never occurs on the scalp 
alone. Alopecia areata presents more or less circular bald 
areas, but these are white, smooth, and of normal texture, 
and there is no fungous growth in the hair. Alopecia from 
syphilis in its early stage resembles favus more closely than 
any other disease of the scalp. But it occurs primarily at 
a later age than does favus, it comes on more suddenly, 
there is no history of crusts, and there will be other evidences 
of syphilis on the body, and (especially in women) the broken 
arch of the eye-brows. 

Treatment. In the treatment of the disease we need 
three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling the 
hair out systematically from day to day so that eventually 
all the hair of the scalp is plucked. To do this we may use 

Fig. 22. 




Piffard's epilating iorceps. 

the epilating forceps (Fig. 22) ; or Kaposi's method of 
grasping the hair between the thumb and a spatula or piece 
of stiff cardboard held firmly in the hand; or, in dispensary 
practice, we may employ epilating sticks, made, according to 
Bulkley, of — 

R- Cerse flavse, .^iij- 

Laccse in tabulis ^iv. 

Picis burgundies?, % x. 

Gummi damar. Sjss. M. 

These ingredients are to be melted together, and then 
moulded into sticks of a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. When 
cold they are to be suddenly twisted off, when, of course, 
they will bring many hairs with them. The " calotte," or 
pitch- cap, used to be used for this purpose, but was given 



230 DISEASES OF THE SKIN. 

up because it caused the death of several patients. Kaposi's 
method is the best of all. If the head is greatly crusted, 
the crusts should be cleaned off by means of soaking the 
scalp with oil for a day or two, and then washing with soap 
and water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil with three per cent, of carbolic or sali- 
cylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent the 
spread of the fungus upon the scalp of the patient, and to 
other people's scalps. After the first washing we should 
allow the scalp to go unwashed for a week or more at a time, 
so as to permit of the full action of the parasiticide. 

After the cleansing and the epilation, the parasiticide 
must be rubbed and worked into the scalp. Of these there 
are many from which to choose. Sulphur ointment is one 
of the best, if properly and persistently used. Other oint- 
ments are thymol, naphthol, resorcin, and pyrogallol in 5 
to 10 per cent, strengths, and those of the ammoniate or 
yellow sulphate of mercury. Or solutions may be employed, 
as bichloride of mercury, two grains to the ounce of ether 
or alcohol ; the oleate of mercury or copper, 10 to 20 per 
cent. ; tar ; oil of cade ; creasote in ether or alcohol ; sul- 
phurous acid in full strength ; or salicylic acid, five per 
cent, in oil. Hydronaphthol plaster does good service in 
favus used according to the method described under Tricho- 
phytosis, which see. Peroni 1 recommends spraying the head 
with acetic acid used in an atomizer, after covering any ex- 
coriated points with diachylon ointment on a piece of cloth. 
At first the scalp feels cold. Hyperemia follows, which 
last about forty-eight hours, and disappears leaving slight 
desquamation. When the hyperemia lessens, the acid is to 
be again used. When there are no excoriations the head is 
to be washed every morning and evening with water and 
corrosive sublimate soap. Busquet 2 recommends sopping on 
daily a solution of 

R. Essence of cinnamon, 10 1 

Spts. ether, sulph., 30 1 M. 

1 Annal. Derm, et Svph., 1891, ii. 797. 

2 Ibid., 1892, ii._269. 



FAVUS. 231 

Besnier and Doyon 1 recommend as a preparatory treat- 
ment for favus that the hair be cut from off and around all 
the patches, and the whole head then covered for two or 
three hours with equal parts of soft-soap and lard. This 
is to be washed off with warm water, and the head to be 
kept covered during the night with a cap of rubber or other 
impermeable cloth. The next morning the head is to be 
washed perfectly clean, bathed with a solution of boric acid 
(25 to 1000), and covered with borated lint soaked in the 
following solution : 



R 



Sodii salicylati, 


25 


Sodii bicarbonati, 


10 


Aqua?, 


1000 



M. 



Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean, and 
then epilation must be practised, the hairs being pulled not 
only from the patches but for about a half-inch about them. 
Epilation is to be repeated every week until no longer any 
trace of redness about the hairs exists, and the head is to be 
kept covered with the impermeable cap. Every evening the 
whole head is to be rubbed with an antiparasitic ointment 
such as : 

R . Bals. Peruv. vel 

01. cadini, 2 to 5 parts. 

Ac.salicyl.,) u ± g „ 

Kesorcm., J 

Sulph. precip., 5 to 15 " 

Lanolini, ") 

Yaselini, >- aa p. a\ ad 100 parts. 

Adepis, J M, 

Every morning the whole scalp is washed with tar soap, 
and each favic patch is soaked with the following : 

R. Alcoholis (90 per cent.), 100 parts. 

Ac. acetic, (crystals), j to 1 part. 
Ac. boric, 2 parts 

Chloroformi, 5 " M. 

Then each patch is to be accurately covered with mercu- 
rial plaster. 

1 French ed. Kaposi's Mai. de la Peau. Paris, 1S91. 



232 DISEASES OF THE SKIN. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a parasiti- 
cide. 

Favus of the nail may be treated by the constant applica- 
tion of a mercurial, resorcin, or hydronaphthol plaster. If 
the disease is limited to one or two points they may be cut 
down upon and the remedy applied directly. Sometimes it 
may be necessary to remove the whole nail. 

After a case of favus has been faithfully treated for a num- 
ber of weeks and looks as if it were well, it should be let 
alone and watched carefully for a long time. Any red 
point that appears is evidence that the disease is cropping up 
again, and should be immediately attacked. 

Prognosis. The prognosis is good, provided the case is 
faithfully and energetically treated. Relapses will surely 
occur if any of the fungus remains in the scalp. A cure 
takes months or years to effect. Favus of the nail is spe- 
cially rebellious to treatment, and may cause permanent 
destruction of the nail. 

Feuergurtel, See Zoster. 
Feuermal. See Naevus. 

Fibroma (Fi-bro'ma 3 ). Synonyms : Fibroma molluscum ; 
Molluscum fibrosum ; Molluscum simplex ; Molluscum 
pendulum. 

Fibromata are soft tumors of the skin that are composed 
of a hyperplasia of the connective tissue as well as the 
subcutaneous tissue, and occur in various shapes, colors, 
and sizes. The most commonly encountered form of 
fibroma is molluscum fibrosum. These may be of the 
color of the skin, or pinkish, or even brownish, or brown- 
ish-red ; most commonly they are of normal color. They 
may be rounded, flattened, sessile, or pedunculated, but 
always raised above the level of the skin. They may 
hang down like polypi. The skin over them feels soft 
and of normal texture, or it may be thickened, or atro- 
phied. A hair sometimes grows from them. There may 
be but one or two present, or there may be hundreds 
of them so that the body is strewn over from head to foot 



FIBROMA. 



233 



with the variously shaped tumors. The trunk is the most 
common location for fibromata, but they may occur on all 
parts and involve even the mucous membranes. (Fig. 23.) 
They give rise to no inconvenience except on account of 



Fig. 23. 




Multiple fibromata. 1 

their size, which sometimes may be that oi a child's head. 
Their usual size is from that of a cherry to that of a walnut. 
Many of them show a slow growth, while many are station- 
ary, and some may involute. Comedones of large size may 
accidentally form in some fibromata. The larger ones may 

1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. 



234 DISEASES OF THE SKIN. 

ulcerate. All of them feel soft, while the larger ones may 
be elastic to the touch. When they hang down in the forms 
of large skin-folds which have undergone hypertrophy, the 
term fibroma pendulum is applied to them. Dermatolysis 
(which see) has been considered as a form of fibroma. Ac- 
cording to some authorities fibrous moles and soft warts are 
but forms of fibroma. 

Etiology. Fibromata usually appear in childhood, 
though they may not do so until later in life. They are 
sometimes hereditary. They tend to increase with advan- 
cing age — that is, they are not so large or numerous in chil- 
dren as in adults. Hebra taught that these children were 
stunted both physically and mentally, but this is not always 
true. By some authorities they are regarded as related to 
neuro fibromata. 

Diagnosis. Molluscum fibroma differs from molluscum 
contagiosum by not having a central depression, and by 
being of the normal color of the skin. They are also usually 
far more numerous. From fatty tumors they differ in not 
being tabulated, and in being pedunculated, and less flat. 
Sebaceous cysts are not so numerous, and their contents 
can be squeezed out to large extent, while fibromata are 
solid. 

Treatment. They may be snipped off with scissors or 
tied off with ligature if pedunculated. If non-pedunculated 
they may be destroyed by electrotysis, or excised. If of 
large size they must be excised. The galvano-cautery may 
be used to destroy any form. 

Fibroma Fungoides. See Mycosis fungoide. 

Fibroma Lipomatodes. * See Xanthoma. 

Fibroma Molluscum. See Fibroma. 

Fibromyoma. See Myoma. 

Figwart. See Verruca 

Filaria Sanguinis Hominis. See Elephantiasis. 

Filaria Medinensis. See Guinea worm. 

Finnen, See Acne. 

Fischschuppenausschlag. See Ichthyosis. 



FOLLICULITIS DECALVANS. 235 

Fish-skin Disease. See Ichthyosis. 

Flachenkatarrh der Haut. See Eczema, 

Flachenkrebs. See Epithelioma. 

Fleckenmal. See Nsevus pigmentosus. 

Flechten. May mean Herpes, or (nassende) Eczema, or 
(fressende) Lupus. 

Fluxus Sebaceus. See Seborrhcea. 

Folliculitis Barbae. See Sycosis. 

Folliculitis Decalvans. Under the name of folliculites et 
perifolliculites decalvantes ac/minees, Brocq has described 
a form of inflammation of the hair follicle closely allied to 
sycosis to which Besnier has given the name of aloj^ecies 
cicatricielles innominees. It is characterized by an inflam- 
matory process, which results in complete destruction of the 
hair papillae, and the formation of cicatricial tissue ; and by 
a tendency for its lesions to aggregate themselves in groups. 
Besnier 1 reported a case of this in 1889. He says that it 
is the same thing that has been called acne lupoide and 
folliculite epilante. In the case reported the disease affected 
all the posterior part of the scalp, which was sown over 
with disseminated patches of baldness of unequal size, 
irregular shape, and serpiginous They were depressed in 
the centre, which was smooth, polished, thinned, cicatricial, 
and completely bald. Their borders were not well defined, 
but merged into the islands of healthy hair. The scalp 
between the borders and the centre of the patches was bald, 
of variegated redness with some hairs broken off at the sur- 
face of the scalp. In the funnel-shaped openings of the 
hair follicles there were little superficial collections of pus. 
Some of the patches were torn by scratching, and others 
looked precisely like those of alopecia areata, Avithout signs 
of inflammation. All treatment seemed to be in vain, and 
the scalp bore only the mildest applications. 

Another variety of folliculitis decalvans is that described by 
Quinquaud. It affects most often the scalp hair, more rarely 
that of the beard, pubes, and axillary region. It produces 

1 Annal. Derm, et Syph., 1889, x. 104. 



236 DISEASES OF THE SKIN. 

irregularly shaped areas of baldness, which are quite smooth, 
polished, pale, atrophic-looking, and presenting at some 
points slight redness. The areas are disseminated, about the 
size of a franc-piece, separated by islands of healthy hair. 
The bald spots are slightly depressed. At the peripheries 
of the patches or in the islands of healthy hair between 
them, will be found pin-head, discrete pustules about the 
hairs. The latter are easily plucked or fall spontaneously. 
Or we find simply, punctiform, isolated red spots which 
may or may not be scaly ; or a reel, elevated, inflamed 
follicle. The fall of neighboring hairs produces the bald 
patches. The disease is very chronic and marked by a 
series of outbreaks. A micrococcus has been found in prob- 
able causative connection with the disease. 

Treatment. The treatment found to be most efficacious 
is to clean the scalp with soap and water ; to paint the dis- 
eased patches and their vicinage with the tincture of iodine ; 
and to bathe the same every morning Avith the following : 

15 



R . Hydrarg. biniod., 


gr- .1 ; 




Hydrarg. bichlor., 


gr. iv ; 


1 


Alcohol., 


^ss; 


GO 


Aquoe destil., 


ad ^ iv ; 


500 



M. 

This will check the disease, but the baldness is irremedi- 
able. (Brocq.) 

Folliculitis Rubra. See Keratosis pilaris. 
Fragilitas Crinium. Sec Atrophia pilorum propria. 
Frambcesia. See Yaws. 
Freckles. See Lentigo. 
Frieselausschlag. See Miliaria. 

Fungous Foot of India. Synonyms : Madura foot ; 
Mycetoma ; Podelcoma ; Ulcus grave ; Tubercular disease 
of the foot. 

This is a disease that is endemic in certain parts of India, 
but has been met with in this country. Though usually 
affecting the foot and leg, it is seen occasionally on the 
hands, shoulders, and scrotum. According to Crocker 
there are two varieties, the pale and the black, the latter 



FURUNCULUS. 237 

being the most common. It may begin with slight conges- 
tion of the affected part ; or as a local induration, either 
superficial or deeply seated, of some part of the foot, which 
is firmer, larger, more diffused and less painful than a boil. 
When this is opened it discharges pus at first, later granules 
like poppy seeds, or mulberry-like masses are mingled with 
the discharge. Or it may begin as a blackish or bluish 
mottled discoloration like tatoo puncta. The progress of 
the disease is slow, but in the course of a few years the foot 
becomes swollen and distorted, the arch being broken, the 
toes being over- extended, and the sole convex from behind 
forward. It becomes dotted over with the raised orifices 
of sinuses extending deep down into the tissues, and giving 
vent to the above-described discharge. 

It is more common in males than in females, and rare 
before puberty. It does not occur in Europeans. Its origin 
is obscure, though it is supposed to be due to a fungus. 
Surgical interference is the only hope for a cure. 

Furunculus (Fu^ruVku^-uV). Synonyms : (Fr.) Fur- 
oncle, Clou ; (Ger.) Blutschwar ; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation round 
a skin gland or follicle, characterized by one or more round, 
more or less acuminated, firm, painful formations, and 
usually terminating by necrosis and suppuration. (Foster.) 

Symptoms. This is a common and familiar disease of 
the skin. Its most frequent locations are the back of the 
neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, painful 
spot, which, in two or three days, enlarges to attain the 
size of a split-pea or silver quarter- or half-dollar. It is 
now raised above the surface, hard, of a dark-red color at 
the centre with the redness fading aw T ay into the sound skin, 
more or less pyramidal in shape, exquisitely tender to the 
touch, and with a most agonizing throbbing pain. Its centre 
soon becomes yellow, indicating the point at which sup- 
puration has taken place, and where it will open. From 
the opening comes the " core," a greenish-gray or whitish 
pultaceous mass mixed with pus and blood. With the es- 



238 DISEASES OF THE SKIN. 

cape of this, all the symptoms subside and the cavity fills 
up by granulation, leaving more or less of a scar. The 
course of the individual boil is from seven to ten or fifteen 
days. At times suppuration does not take place, but the 
mass undergoes resolution. This is the so-called " blind 
boil." 

There may be but one boil, or there may be hundreds of 
them. They come out in crops of from two to half a dozen 
at a time. If very numerous, or of large size, they give 
rise to constitutional disturbance. They may continue to 
form for weeks, months, or even years if left untreated. 
This is what is called furuneulosis. 

Boils are always isolated. They may be confined to one 
spot, or come out in a number of regions at the same time. 
There may be sympathetic enlargement of the neighboring 
lymphatics. If the disease is extensive the patient presents 
a truly pitiable condition. 

If a boil starts from a sweat gland it resembles that 
which originates in a sebaceous gland, except, according to 
Crocker, it has no mattery head and is somewhat less in- 
durated. This form of boil is called " hydro-adenitis " by 
Verneuil and Bazin. It is of the size of a pea, and is most 
often met with in the axillae, about the anus and perineum, 
near the nipples, and may form anywhere where there are 
sweat glands, excepting on the soles of the feet. 

Boils may occur in the external auditory canal in con- 
junction with the disease elsewhere. They are exceedingly 
painful, and produce deafness. One or both ears may be 
affected, but usually it is only one ear. They may set up 
inflammation of the entire canal and tympanum ; one case 
of this sort has ended fatally. If the furuncle is situated 
in the posterior wall of the canal, or a general inflammation 
has been set up, considerable redness and tumefaction over 
the mastoid region may occur. (Dr. A. Rupp. 1 ) 

Etiology. In this bacteriological age the cause of fu- 
runcles is believed to be the entrance into the skin of the 
staphylococcus pyogenes aureus et albus. It would certainly 

1 Personally communicated. 



FUKUNCULUS. 239 

seem that local infection does play a part in the production 
of crops of boils occurring in one region, and the doctrine 
of local infection finds further support in the results of 
treatment by antiseptics. It must be remembered that these 
micrococci are widely distributed, having been found in dish- 
water, in the superficial layers of decayed vegetable matter, 
in the swaddling-clothes of healthy infants, in the dirt 
under the finger-nails, and in numerous other places. Like 
other parasites, these require some peculiarity of soil for 
their growth, or at least an opportunity for gaining entrance 
to the glandular apparatus of the skin. The soil is afforded 
in lowered vitality of the skin, and thus we find boils in 
diabetes mellitus, after specific fevers, in anaemia, lithsemia, 
uraemia, and septicaemia ; and as a complication of other 
skin diseases, such as eczema, prurigo, and scabies. In many 
cases no disorder of the general health can be discovered. 
The second condition is fulfilled by local injury to the skin, 
such as friction or pressure, or scratching. It is probable 
that they are contagious, as they are certainly auto- 
inoculable, and can be produced by inoculation of pure cul- 
tures of the micrococcus. The popular notion of their 
origin from too good living is only another way of saying 
that they occur in individuals not in perfect health. 

Pathology. The inflammation begins in the corium and 
deeper tissues in or about the hair follicles or glands of the 
skin. " The mechanism of the process is supposed by some 
to be that the vessels around the gland or follicle become 
blocked, producing its death, and inflammation is then set 
up round the necrosed tissue to get rid of it by suppuration." 
(Crocker.) 

Diagnosis. The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. In most cases there is no need of internal 
treatment. If the patient is out of health in any way we 
should endeavor to help him back to his normal condition. 
In furunculosis we should always bear in mind the proba- 
bility of there being diabetes mellitus at the bottom of the 
mischief, seek for it, and do our best to cure the patient if 



240 DISEASES OF THE SKIN". 

we find evidence of it. As a rule, tonics are called for. 
There are many drugs recommended for the treatment of 
boils, apart from constitutional conditions. Of these, sulphide 
of calcium is one of the most popular, one-tenth of a grain 
being given every two or three hours, or a fourth- to a half- 
grain three or four times a day. Piffard speaks well of the 
compound syrup of the hypophosphites, a dessertspoonful 
three times a day. Hardy recommends tar- water up to a 
quart a day. The sulphite or hyposulphite of sodium in 
fifteen- to twenty-grain dose three times a day, is also well 
spoken of. Yeast is a homely but efficient remedy, either a 
half-wineglassful being taken night and morning or a like 
quantity in divided doses, or one of Fleischmann's yeast 
cakes being eaten during the day. Le Gendre, 1 believing 
that boils may arise from the absorption of imperfect prod- 
ucts of digestion, advises the disinfection of the intestinal 
tract by the use of the following powder : 



Be . 0-Naphthol 

Bismuth, sal icylat., \- aa gr. ivss; 

Magnesia carb., 



30 

M. 



which is to be given every four hours. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, the 
heat and moisture only facilitate the growth of the same, 
and the production of new boils. That new boils are apt to 
spring up about a poulticed boil is a common experience. 
"Hands off" is the rule for young boils, nor should old 
ones be squeezed. We should endeavor to abort the de- 
velopment of a boil. To do this there are various approved 
methods, but the one most highly commended is the use of 
carbolic acid. This may be either by touching them with 
pure carbolic acid ; injecting them with a few drops of a two 
per cent, solution ; or spraying them with the same solution 
for fifteen minutes at a time eight times during the day, and 
keeping them covered with carbolized dressings in the mean- 
time. Mercury may be used instead of carbolic acid, the 
boil beingkept covered with emplastrum hydrarg. with a little 

1 Union Med., 1888, xlv. 98. 



FURUNCULUS. ' 241 

hole cut in the plaster to correspond to the centre of the 
boil ; or an ointment of the nitrate or red oxide may be used. 
Painting with iodine is also commended ; as well as keeping 
them covered with a saturated solution of boric acid, or an 
eight or ten per cent, plaster or ointment of salicylic acid. 
Hardaway speaks highly of Unna's carbolic acid and mer- 
cury mull plaster. Electrolysis to destroy the follicle is 
spoken of by the same authority. 

When aborting is out of the question, it is a good plan 
to thrust a little pure carbolic acid into the central opening. 
It hurts for a few minutes only, and is promptly curative. 
The boil should then be dressed with carbolized vaseline or 
a boric acid ointment. Or it may be opened and dressed 
with iodoform, or aristol, as the odor of the former is objec- 
tionable. Here too the mull plaster of carbolic acid and 
mercury may be used. Instead of the pure carbolic acid, 
Crocker advises the glycerole of carbolic acid of the British 
Pharmacopoeia. 

Furuncles of the ear. My friend Dr. A. Rupp, aural 
surgeon to the New York Eye and Ear Infirmary, has 
kindly advised me on this head as follows : If the auditory 
canal be filled or unclean, it must be syringed out with a two 
to five per cent, solution of carbolic acid followed by a solu- 
tion of bicarbonate of soda as hot as can be comfortably 
borne. 

The canal is to be dried with absorbent cotton, and if the 
membrana tympani is intact, filled with — 



R . Hydrarg. biclilor., gr. v. 

Glycerini, \ .. z- 

Alcoholis, J ^J ' 



30 



M. 



which is to remain in some minutes, and then the excess is 
allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. If the membrana 
tympani is deficient, the whole canal is to be filled with 
powdered boric acid, and the orifice closed as before. In 
either case the cotton is to be changed when soiled. When 
furuncles are at the inner end of the canal near the mem- 
brana tympani, a leech or two in front and a little above the 

11 



242 DISEASES OF THE SKIN. 

tragus will afford mucli relief. It is unnecessary to incise 
the furuncles except where pus has formed and has no outlet. 

Furunculus Orientalis. See Aleppo boil. 

Gale. See Scabies. 

Gangrene of the Skin. See Dermatitis gangrenosa. 

Gansehaut. See Cutis anserina. 

Gefassmaler. See Nsevus vasculosus. 

Geromorphisme Cutane is the name chosen by Drs. 
Souques and Charcot 1 to designate an affection producing 
changes in the skin of a girl eleven years of age so that she 
looked like an old woman. The expression of the face sug- 
gested that due to facial paralysis. The skin hung in loose 
folds and was flabby like the skin sometimes seen in very 
old people. Apart from loss of natural consistence and 
elasticity there was no change in the skin. If lifted up, 
twisted or folded in any way, it returned very slowly to its 
normal position ; and it was abnormally movable over the 
subcutaneous tissues, in these things suggesting that form of 
dermatolysis called " elastic skin." There were no changes 
in the hair, nails, or teeth. There was no assignable cause 
for the condition, which was preserved unaltered during an 
interval of ten years from the first to the last time that the 
doctors saw the case. 

Geschwulst is the German for tumor. 

Geschwiire. See Ulcers. 

Gesichtsatrophie. See Hemiatrophia facialis. 

Glanders. See Equinia. 

Glanzhaut. See Atrophoderma idiopathica. 

Glossy Skin. See Atrophoderma idiopathica. 

Gneis. See Seborrhcea sicca. 

Gommes Scrofuleuses. See Scrofuloderma. 

Goose-flesh. See Cutis anserina. 

Granulationsgeschwulste (Grer.). Connective-tissue new 
growths. 

1 Nouvelle Iconographie de la Salpetriere. 



H^MATIDROSIS. 243 

Granuloma Fungoides. See Mycosis fungo'ides. 

Greisenhaftigheit der Kinder. See Sclerema neona- 
torum. 

Grocers' Itch is eczema of the hand. 

Grutum. See Milium. 

Grutzgeschwulst. See Atheroma. 

Guinea-worm Disease or Dracontiasis is met with en- 
demically in tropical climates. It is caused by the larvae of 
the Guinea-worm, or filaria medinensis, being swallowed, and 
developing in the body. The female makes its way into the 
muscles, and within nine to twelve months gives rise to the 
symptoms of the disease. The male probably dies and is 
passed out of the body. The symptoms of the disease are a 
small tumor under the skin that feels like a coil of soft 
string; the appearance of a pea- to filbert-sized vesicle upon 
this when the animal is about to escape ; tension, pain, and 
itching; in severe cases inflammation, purulent discharge, 
hectic fever, and perhaps delirium. The worm is either 
gradually wholly extruded after the vesicle breaks, or a 
new tumor forms after a part has escaped, and this after a 
time breaks, and the rest of the worm comes away. There 
may be only one worm or a legion of them. They are 
located most often in the foot, but may be found anywhere. 

Treatment. The treatment of the disease is to remove 
the worm, which is done by winding it carefully around a 
stick when the head is protruded, giving a turn or two every 
day until the worm is extracted. Tincture of assafoetida in 
doses of one or two drachms three times a day kills the 
worm, before extraction. 

Gumma. See Syphilis. 

Gune. See Tinea imbricata. 

Gurtelkrankheit. See Zoster. 

Gutta Rosea. See Rosacea. 

Haarmenschen. See Hypertrichosis. 

Haematidrosis(He 2 m-a 2 t-i 2 -dro / si 2 s) or Haemidrosis(He 2 m- 
i 2 dro r -si 2 s) is a rare disease of the sweat glands in which, on 
account of an effusion of blood into the coils and their ducts 



244 DISEASES OF THE SKIN. 

by diapedesis from the surrounding vascular plexus, blood is 
discharged upon the skin along with the sweat. The sub- 
jects are apt to be hysterical young women, though the 
affection has been seen in newborn children. It is in some 
cases vicarious menstruation. The points of election are the 
face, ear, umbilicus, hands and feet. Ephidrosis cruenta 
and bleeding stigmata are other names for the curious malady. 
The treatment should be directed to the condition of the 
individual. 

Hsemorrhcea Petechialis. See Purpura. 
Hautfinne. See Acne. 
Hauthorn. See Cornu cutaneum. 
Hautgries. See Milium. 
Hautkrebs. See Epithelioma. 
Hautsclerem. See Scleroderma. 
Hemorrhagic Cutanee. See Purpura. 

Herpes (Hu 5 r-pez). An acute inflammatory disease of 
the skin characterized by an eruption of one or more groups 
of vesicles upon reddened bases. 

There are two main varieties of the disease : one occur- 
ring upon the face, herpes facialis ; and one occurring upon 
the genitals, herpes pro genitalis. 

Symptoms. Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister or cold sore, 
usually occurs upon the lower part of the face, about the 
mouth (Fig. 24). There is commonly some slight disturb- 
ance of the general economy, not as part of the disease, 
but as the cause of it. The patient first notices more or less 
marked burning, stinging, or itching in the part, and perhaps 
at the same time erythematous papules may form. After a 
few hours a number of pinhead- to pea-sized, clear, fully dis- 
tended vesicles will appear upon an erythematous base. 
Perhaps the herpetic patch may appear suddenly without 
antecedent erythema. There is usually not more than one 
or two patches of small size. There may be a score or more 
of them, and they may be of large size. The patches are 
always irregular in shape. There may be but two or three 






HERPES. 



245 



vesicles in a group, or there may be a dozen of them. 
Thev do not tend to break down of themselves, but after a 
few days dry up into a crust which falls and leaves a red 
spot that soon disappears. Sometimes the vesicles may 
coalesce into bullae. The duration of the disease is about 



Fig. 24. 






Herpes febrilis. 



eight or ten days. The most common location is upon the 
upper lip, but it may be anywhere upon the face, and not 
uncommonly bilateral. The mucous membrane of the 
mouth may also be involved, but here, owing to the heat 
and moisture, the vesicles are seldom seen, as they break 
down and leave excoriated points. There is a strong tend- 



246 DISEASES OF THE SKIN. 

ency for the disease to recur with the recurrence of the 
exciting cause. 

Etiology. It is still an undetermined question whether 
herpes facialis is a zoster or not. By most authorities it is 
considered to be an independent disease ; by a few it is 
thought to be an incomplete zoster. It is known to occur 
with catarrhal inflammations of mucous membranes, such as 
a coryza or a bronchitis; with digestive derangements, as gas- 
tritis or enteritis ; with various febrile diseases, such as 
pneumonia, and the fevers in general, and it is very often 
seen in women as a herald of the menstrual epoch, occur- 
ring with great regularity for years. It arises sometimes 
on account of an injury to the terminal ends of the nerves, 
and as such injuries are liable to occur in the tender mucous 
membrane of the lips, this may be an explanation of its 
frequency about the mouth. Infection has been invoked 
by a few observers as a cause, but this is not proven. It is 
evidently a neurosis. Sometimes it occurs coincidently with 
herpes progenitalis, or with zoster. 

Diagnosis. It must be diagnosticated from zoster, and 
from vesicular eczema. From zoster it differs in not occurring 
in a series of groups scattered along the course of distribu- 
tion of the trigeminus; and in frequently being bilateral. 
Generally speaking there is more marked neuralgia in 
zoster, though in some cases this is wanting. From eczema 
it differs in the large size of its vesicles, in their showing 
no tendency to break down, in being less pruriginous, in 
running a regular course and rapidly recovering by the 
simple drying up of the vesicles. 

Treatment. Left to itself the disease will speedily get 
well, and really requires no treatment beyond protection 
with flexible collodion, or any indifferent soothing lotion or 
ointment. We are often asked if we cannot prevent or 
abort the disease when due to the menstrual flux. Women 
know well that the application of spirits of camphor will 
sometimes do this. Hardaway recommends rubbing the 
part with borax. Or one of the alcoholic solutions recom- 
mended by Leloir for this purpose in herpes progenitalis 
may be used, namely, either 2 per cent, resorcin, 1 per cent. 



HERPES. 247 

thymol, 3 per cent, menthol, or 2 per cent, tannin frequently 
applied. 

Herpes pro genitalis. This has been called herpes pre- 
putials, but as it occurs in women as well as men and on 
other places than the prepuce, that name is obviously incor- 
rect. 

Symptoms. The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 
upon an erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear with 
serous contents, and if on moist locations, as under the pre- 
puce or about the mucous membranes of the female geni- 
tals, they soon break down and leave tiny excoriations. 
There may be but one or several patches of herpes. The 
disease runs a course of eight or ten days and gets well of 
itself, unless irritated under the mistaken idea of its being 
a chancroid. 

According to Bergh, 1 who has made a careful study of the 
disease, in women the groups usually contain five to eight 
pin-head to hemp-seed vesicles, but may have twenty to 
thirty-five millet to popy seed sized vesicles. Around each 
group is a reddish areola. The vesicles are isolated, and 
seldom confluent. Itching is apt to precede their outbreak. 
There may also be slight tenderness or swelling of the 
neighboring glands. In both sexes the patches may be 
unilateral, bilateral, or median. In men it occurs most 
frequently on the inner surface of the prepuce, then on its 
outer surface, the sulcus, glans, meatus, sheath of the penis, 
and rarely in the meatus. In women, Bergh found it most 
often on the labia majora, then the labia minora, and ano- 
genital region ; seldom on the clitoris or in the vestibule ; 
very rarely on the cervix uteri. Unna 2 gives the order of 
frequency as labia minora, clitoris, labia majora, introitus 
vaginae et carunculae myrtiformes, perineum, anal region, 
genito-crural fold, mons veneris, and mucous membrane of 
anus and vagina. The disease has a tendency to relapse, 

1 Monatshefte f. prakt Derrnat , 1890, x. 1. 

2 Journ. Cutan. and Ven Dis ., 1883-4, i. 321. 



248 DISEASES OF THE SKIN. 

in men with each coitus, in women with each menstrual 
period. It is very common in women to have herpes of the 
face at the same time, and this has been noted in men. 

Etiology. The cause of the disease is congestion of the 
genital region. Thus in men it is frequently seen two or 
three days after each coitus; or accompanying a gonor- 
rhoea or chancre (soft sore). A long prepuce seems to pre- 
dispose to it. In women it comes in 80 per cent, of the 
cases with menstruation (Bergh), and in them it does not 
seem to have any marked relation to the sexual act. It is 
also seen in connection with pregnancy and the puerperal 
state. It is a not infrequent disease. Greenough 1 met 
with it in men in about 17 per cent, of all venereal cases in 
private practice. In women there are no statistics from 
private practice, and, indeed, it is in this country but rarely 
reported. Both Bergh and Unna, however, met with it 
very frequently in public prostitutes in St. Petersburg and 
Hamburg. 

Diagnosis. The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic stand- 
point on account of its liability to be taken for chancre (soft 
sore), or for the initial lesion of syphilis. This can hardly 
occur if the vesicles are seen, but when they are no longer 
present some difficulty may arise. From chancre the 
superficial character of the lesion points toward herpes. In 
case of doubt the use of a simple dusting-powder for a day 
or two will clear up the difficulty, because the chancre will 
continue to enlarge while the herpes will become well. 
Auto-inoculation will afford positive evidence. From the 
inital lesion of syphilis herpes differs in the absence of all 
induration of its base, and in the inflammatory character of 
the lesion. Here again a short wait will clear up the diag- 
nosis. 

Treatment. Herpes progeni talis will usually promptly 
disappear by the use of a dusting powder of bismuth, or 
oxide of zinc and starch ; or by covering it with a piece of 
lint soaked in an astringent solution, such as a weak lotion 

1 Archiv. Dermat., 1881, vii. 1. 



HERPETIDE. 249 

of liquor plumbi subacetatis. If suppuration has occurred 
on account of bad treatment, and the glands are enlarged or 
tender, the patient had best be put in bed. Circumcision 
has been recommended to prevent recurrences, but is of 
doubtful effiacy. It is well to have the patient wash the 
parts daily, and after coitus. Marriage and fidelity to the 
wife are good means of curing a relapsing herpes. Astrin- 
gent washes are useful in both sexes. If the " habit " of 
herpes progenitalis, as it may be termed, has been formed, 
careful hygienic and general treatment may be necessary for 
a cure. Leloir's directions, as given under herpes facialis, 
may be tried for aborting the disease. 

Herpes Circinatus is either erythema iris or trichophy- 
tosis corporis. 

Herpes Circinatus Bullosus was the name given by Wilson 
to what has since been called Herpes gestationis. 

Herpes Cretace. See Lupus erythematosus. 

Herpes Esthiomenes. See Lupus vulgaris. 

Herpes Gestationis is regarded as being a dermatitis her- 
petiformis occurring during and provoked by pregnancy. 
It is prone to relapse with each succeeding pregnancy ; and 
slowly subsides after delivery. Apart from its etiological 
relation, it corresponds closely to dermatitis herpetiformis, 
which see. 

Herpes Imbrique. See Trichophytosis corporis. 

Herpes Parasitaires. See Trichophytosis corporis. 

Herpes Iris. See Erythema Iris. 

Herpes Phlyctaenoides. See Zoster. 

Herpes Tonsurans, seu Tonsurant. See Trichophytosis 
capitis. 

Herpes Tonsurans Muculosus. See Pityriasis rosea. 
Herpes Zoster. See Zoster. 

Herpetide Maligne Exfoliative. See Dermatitis ex- 
foliativa. 

Herpetide (E 2 r-pa-ted). This is a class of skin disease 
which depend upon what the French writers call the her- 

11* 



250 DISEASES OF THE SKIN. 

petic diathesis. The affections in this class are marked by 
long duration ; obstinacy to treatment ; tendency to relapse ; 
and more or less pain and discomfort. Under it are included 
eczema, the lichens, psoriasis, and prurigo. 

Hirsuties. See Hypertrichosis. 

Homines Pilosi. See Hypertrichosis. 

Homines Sylvestris. See Hypertrichosis. 

Honey-comb Ringworm. See Favus. 

Horn. See Cornua cutaneum. 

Hiihnerauge. See Clavus. 

Hydradenomes Eruptifs. See Adenoma of sweat glands. 

Hydroa (Hi-dro'-a 3 ) is practically dermatitis herpetiformis. 
It is an old term recently revived, aud is of uncertain sig- 
nificance. By some it is used to designate eruptions that 
are midway between erythema multiforme and pemphigus. 
As dermatitis herpetiformis certainly comprises what has 
been described as hydroa, I shall consider the latter no fur- 
ther. All the different forms of hydroa, such as H. vaccini- 
forme of Bazin ; H. vesiculeux, etc., may well be dropped 
from our nomenclature. 

Hydroa Bulleux. See Erythema iris. 

Hydro-adenitis. See Furunculus of sweat glands. 

Hygroma Cysticum Colli Congenitum. See Lymphan- 
gioma. 

Hyperesthesia (Hip-u 5 r-e 2 s-the'-zi 2 -a 3 ). This is that 
condition of the skin in which pain is experienced on the 
slightest contact even of a current of air, in this differing 
from dermatalgia, where the pain is spontaneous. It is a 
neurotic disease and is met with most commonly as a symp- 
tom of other diseases, such as non-tuberculated leprosy, 
hydrophobia, and hysteria. Idiopathic cases are met with, 
though rarely. The hyperesthesia may be general or 
localized, unilateral or symmetrical. 

The treatment is in most cases that of the disease of 
which it is but a symptom. Barbillion 1 cured one case of 

1 Progres Med., 1885, i. 375. 



HYPERIDROSIS. 251 

the idiopathic variety by blisters, and two cases by congela- 
tion by means of methyl chloride. It is probable that cata- 
phoresis by cocaine after the method of Peterson might be 
beneficial. This is done by means of discs of filter-paper 
soaked in cocaine, and placed on a specially made electrode 
attached to the positive pole of a galvanic battery. The 
sponge electrode attached to the negative pole is placed 
indifferently on the skin, and a current of some five milliam- 
peres, if the patient can bear so much, is allowed to pass for 
fifteen or twenty minutes. I have found, by experimenting 
on myself, that lasting anaesthesia is produced, though some 
pain must be endured before it is attained. 

Hyperidrosis (Hip-u 5 r-i 2 d-ro'si 2 s). Synonyms : Ephidro- 
sis ; Idrosis ; Sudatoria ; Polyidrosis ; Excessive Sweating. 

A functional disorder of the sweat glands characterized by 
an excessive flow of sweat. 

Symptoms. Hyperidrosis may be general or localized; 
unilateral or symmetrical ; in large or small amount. The 
cases of general sweating occur most often symptomatically 
in the course of general diseases such as phthisis, malaria, 
and rheumatism, and do not concern us now. Some cases 
occur idiopathically. Such patients are usually fat. The 
hyperidrosis may be constant or at intervals, being excited 
by the slightest irritation of the nervous system, or by mus- 
cular exertion. The outburst of the sweat is generally pre- 
ceded by a prickling sensation. It is apt to be accompanied 
by prickly heat (lichen tropicus). 

We are called upon as dermatologists to treat localized 
sweating more often than the just described variety, and those 
cases occur most commonly upon the palms and soles, in the 
axillae, about the genitals, and on the face and scalp. The 
excessive flow of sweat may be constant, but it is usually 
paroxysmal, and often under the influence of the emotions. 
It is usually more pronounced in warm than in cold 
weather. Eat people are more prone to it than are those 
who are thin ; anaemic and delicate people rather than the 
robust. In some cases there may be a sense of tingling be- 
fore the flow occurs. The affected part may be warm or cold ; 



252 DISEASES OF THE SKIN. 

if the first, it is apt to be somewhat hypersemic. Occur- 
ring in places that are warm and covered, brornidrosis is a 
common accompaniment. The disease may last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweat is only enough to keep them 
more or less constantly moist ; sometimes it is so abundant 
as to drop from the hand and fingers, or even to fill up the 
upturned palm and run over the edge. It spoils gloves, and 
interferes with many forms of work. Sweating soles are 
soon followed by tender feet, the epidermis becoming sodden, 
macerated, and removed. It interferes with walking. 
Sweating in the axillae spoils the clothing, and is only ren- 
dered worse by the rubber dress shields so commonly worn 
by women. In its paroxysmal form it is frequently en- 
countered in patients stripped for examination in public. 
This form has been aptly named, by the French, the mili- 
tary sweat, as it so often is seen in examining recruits for 
the army. Sweating about the genitals is often accompanied 
by intertrigo, which may also occur in other parts subject to 
hyperidrosis where folds of skin are in contact. Sweating 
of the face is most commonly encountered upon the forehead, 
nose, and eyelids, beads of sweat standing out upon them or 
running off in little rivulets. It is here that haemidrosis is 
most common. Upon the scalp it has been observed that 
its occurrence is frequently followed by loss of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead or face, or whole body. Upon the 
forehead and face this form of sweating occurs as an accom- 
paniment of migraine and limited to the painful region ; it 
is in paraplegia that one-half of the body alone is affected. 

Etiology. The disease is probably due to a disturbance 
in the sphere of the sympathetic system. It has followed 
lesions of the cerebro-spinal nerves. It occurs in all classes 
and conditions of men, and in all ages and both sexes. In 
some cases it is hereditary. Ill health seems to be the 
cause in many cases; it maybe anaemia; chlorosis; lith- 
aemia ; hysteria ; or general debility. In any case it is 
purely a functional disease of the sweat glands, they being 
structurally unchanged. 



HYPERIDROSIS. 253 

The diagnosis is so evident that we need not stop to dif- 
ferentiate it systematically. 

Treatment. The condition of the patient's health is to 
be carefully investigated, and tonics, mineral acids, nux 
vomica, or other medicine ordered according to the nature 
of the case. If there is no indication for this plan, or it does 
not succeed, recourse may be had to belladonna or atropia to 
the point of producing their full physiological effect ; or pilo- 
carpine, -£q gr. t. i. d. ; or agaricin in dose of ^ grain ; or 
ergot, half a drachm of the fluid extract t. i. d. Crocker 
has found a fall teaspoon of precipitated sulphur in milk 
twice a day the best remedy. If it loosens the bowels too 
much he prescribes it as follows : 



R • Pulv. cretse co., 
Pulv. cinnam. co., 
Sulph. precip., 
Sig. A teaspoonful twice a day. 



3"j; 


25 


3y; 


15 


3J; 


100 



M, 



The local treatment in many cases is as unsatisfactory as 
the constitutional treatment. There have been many plans 
proposed. Local faradization is one agent. Very hot 
water may be sponged on for a few minutes; belladonna 
ointment or liniment may be rubbed in ; or we may use some 
astringent application, as of bismuth, tannin, alum, sulphate 
of zinc, borax, and the like, in alcohol, ointment, or powder. 
As a rule, ointments cannot be used on the hands and face. 
The strength of the alcoholic solution is 1 to 3 per cent. 
The most reliable of these is probably a saturated solution 
of boric acid, or a 3 per cent, solution of salicylic acid. 
Kaposi speaks highly of the good effect ot bathing the parts 
with a 5 per cent, solution of naphthol in alcohol, and keep- 
ing them powdered with one part of naphthol to one hundred 
of starch. Piffard recommends freshly prepared silicic 
hydrate, one part, in ointment of rose-water, nine parts. 
Sulphate of quinine, 5 per cent, in alcohol, may be tried. 
For sweating of the feet the best means are those given 
under Bromidrosis, w T hich see. Permanganate of potash in 
1 per cent, strength may be used. Unna recommends 
ichthyol in 2J per cent, ointment and the use of ichthyol 
soap. 



254 DISEASES OF THE SKIN. 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hypertrichosis 1 (Hip-e 2 r-trik-ho'-si 2 s). Synonyms : Hir- 
suties ; Trichauxis ; Polytrichia ; Dasyma ; Trichosis hir- 
suties ; (Fr.) Poils accidentels ; Superfluous hair. 

Symptoms. Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, nor- 
mally, only lanugo hairs are present. It may be general 
or partial, congenital or acquired. The general form is also 
congenital, but it is never universal, as no hair grows upon 
the palms and soles, the backs of the last phalanges of the 
fingers and toes, the inside of the labia majora, the prepuce, 
and glans penis. Subjects of this malady are usually born 
covered more or less thickly with hair, which may be light 
or dark in color. This continues growing longer, coarser, 
and darker till it reaches its full development. As a rule, 
the long hair covering the body is fine, resembling more the 
hair of the head than of the beard, as is also the case with 
the hair on the face of these people. With this excessive 
growth of hair there is usually combined a deficiency of 
teeth, specially marked in the upper jaw. Subjects of this 
malady are called homines pilosi and are met with in all 
quarters of the world. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nsevus. The distinction between a localized 
hypertrichosis and a nsevus is made mostly upon the color of 
the underlying skin. In the former case the skin is per- 
fectly normal, while in the latter it is pigmented and may be 
otherwise altered. Thus we have in the Lancet of 1869, ii. 
276, an account of a Mexican woman who had a nsevus pilosus 
extending, like a pair of bathing trousers, from the umbilicus 
anteriorly and the sixth dorsal vertebra posteriorly, to about 
half-way down the thighs, covering the buttocks. Dr. 
Cummin 2 mentions the case of a lady who was noted for the 

1 Jackson, G. T., " Superfluous Hair," Med. Record, May 23, 1885, is 
the basis of this section. 

2 London Medical Gazette, 1836, xix. 263. 



HYPERTRICHOSIS. 255 

beauty of her face, whose body from breast to knee was 
covered with a profusion of black, thick, bristly hair. Wal- 
deyer 1 reports the case of a girl nine years of age, who had 
a lock of hair running from the first to the fourth lumbar 
vertebra, and a smaller one from the third to the fourth cer- 
vical vertebra. These localized and partial cases of hyper- 
trichosis are most frequently met with in the sacral or 
lumbar region, and not infrequently are associated with 
spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an ex- 
cessive growth of hair in regions where it is usually found, 
or of the development of hair in regions usually hairless or 
only provided with downy or lanugo hair, or of the develop- 
ment of pubertal hair at an early age. 

The following cases are instances of excessive growth and 
precocious development. Chowne 2 speaks of a boy, eight 
years of age, who had the whiskers of a man. Beigel 3 has 
seen a six-year old girl with pudenda like a twenty-year 
old woman, both in shape and hair. As cases of excessive 
growth, the following may be mentioned : Leonard 4 men- 
tions the case of a man in his neighborhood whose beard 
measured seven feet six and a half inches in length. Other 
instances of excessive length of beard are met with in medi- 
cal literature. 5 Many men have an excess of hair upon the 
chest and shoulders. Hair is generally better developed 
upon the forearm than upon the upper arm, and upon the 
legs than upon the thighs. As men grow old they are apt 
to have long hair grow from the nostrils and the ears. 
These are instances of the growth of strong hair where 
normally only lanugo hairs are present. 

The growth of the beard in women is the form of hy per- 
trichosis which concerns us most, as it is the deformity which 
we will be called upon to cure. As women grow old, espe- 

1 Atlas der menschl. u. thierisch. Haare. Lahr, 1884. 

2 Lancet, 1852, i 421. 

5 Virchow's Archiv, 1868, xliv. 418. 

* The Hair : its Diseases and Treatment Detroit, 1881. 

5 Jackson : Diseases of the Hair and Scalp. ISew York, 1887. 



256 DISEASES OF THE SKIN. 

cially after they have passed through the climacteric period 
of middle life, a slight mustache or a few straggling dark 
hairs on other parts of the face often appear. These growths 
seldom annoy them much, as they are accepted as evidences 
of advancing years. The case is very different when a 
young woman is afflicted with a beard, and most of the 
patients who apply for relief from their facial hair are between 
twenty and thirty-five years old. The hair generally begins 
to grow so as to be noticeable at about the eighteenth year of 
age. To get rid of the trouble the tweezers are first resorted 
to ; then depilatories are tried ; sometimes burning is at- 
tempted, and as a final refuge the razor is used. All the 
time the hair grows coarser and more abundant. Some of 
these women shun company, keep themselves shut up all day, 
their health deteriorates, and constantly brooding over their 
misfortune, they are prone to become hypochondriacal and 
melancholic. The amount of hair presented by these cases 
varies. Perhaps the commonest growth is a mustache alone. 
In most of my cases the hair has grown thickest and coarsest 
under the chin and upon the front of the throat. It is rare, 
even in the best-developed cases, to have much hair under 
the lower lip. Sometimes the growth is as complete, as 
heavy, and as coarse as is met with in men. The skin of 
many cases is coarse, muddy, greasy, and studded with acne. 
From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and warm. 
In some of these cases the increase is probably more apparent 
than real, the hair not having been rubbed off by friction. 
Likewise, after injury to nerves the hair sometimes becomes 
hypertrophied, only to fall out after recovery. Continued 
irritation of a part, as by blisters, may stimulate hair 
growth which may or may not be transitory. The most 
interesting of this group of cases is that comprising those 
of hirsuties occurring during pregnancy, and disappearing 
again after some months. Wilson reported a case of delayed 
appearance of menstruation in which hair grew upon the 



HYPERTRICHOSIS. 257 

face. After the menstrual function was established, the 
hair ceased to grow and gradually disappeared. 

The cause of hypertrichosis is very obscure in some of 
its forms, while in other varieties we can more readily dis- 
cover it. In general congenital hirsuties heredity plays an 
important part. But hereditary tendencies will not explain 
the first appearance of these congenital cases. Virchow en- 
deavored to account for them upon the theory of nervous 
influence, founded upon the fact that in the Kostroma people 
the lack of development of the teeth and jaws was in the same 
zone as the over-development of the hair on the forehead, nose, 
cheek, and ears ; these regions all being supplied by branches 
of the trigeminus or fifth cranial nerve. (Jnna's theory of 
congenital hypertrichosis is that it is due to a persistence 
of the foetal or primitive hair ; the change of type between 
the primitive and permanent hair not taking place. 

The cause of acquired hirsuties is, in some cases, not far 
to seek. Heat and moisture will apparently increase the 
growth of hair, just as they favor the growth of vegetable 
life. Thus the hair has grown luxuriantly under the stimu- 
lation of poultices, and on the limbs when confined in a 
fracture-box. To these factors must be added an increase 
of the flow of blood to the part. Increase of the flow of 
blood will stimulate hair growth independently of heat and 
moisture. At least Prentiss' case of hair growing more 
luxuriantly and coarser under the use of pilocarpine, which 
causes hyperemia of the skin, would seem to indicate this. 
Hypertrichosis following injury to nerves is probably de- 
pendent upon vasomotor disturbances. The growth of hair 
upon exposed parts, as upon the arms and chest of laboring 
men, sailors, and the like, is due to the local irritation of the 
sun and wind. 

Now we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with derange- 
ment of the uterus and appendages. Because in some 
bearded women there has been some evident derangement 
of the sexual organs, it has been affirmed that some similar 



258 



DISEASES OF THE SKIN. 



derangement is present in all. This is on a par with the 
too loosely accepted idea that too free use of alcohol is the 
only cause of rosacea. In the cases I have met with, the 
majority were as free from uterine trouble as the rest of their 
sex. While it is true that some of these women are of mas- 
culine build, and have a masculine voice, most of them do 
not exhibit these characteristics. In some cases, however, 
there does seem to be some relation between the reproduc- 
tive organs and the growth of the beard. Heredity is often 
well marked. It is improbable that attempts at destroying 
the fine hair causes the development of the coarse hair. It 
is more likely that it only hastens its growth. 

An interesting study of the relation between hirsuties in 
women and insanity was made by Hamilton. 1 He regards 
hair growth on the face in women as the inevitable result of 
the over-active and continuous exercise of the uterine and 
ovarian functions. He believes it to be of neuropathic 
origin, connected with disorders of the fifth cranial nerve ; 
and that when it occurs upon the face of an insane person 
it is indicative of an unfavorable form of insanity, especially 
if the subject had not reached middle life. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way : While at times there appears to be a 
relation between the uterine, or more properly, the menstrual 
function, and the growth of hair on the face, shown by a 
decrease or deficiency of the first, and an increase of the 
second, still in the majority of cases no such relation is 
discoverable, and it must be viewed as a deformity or freak 
of Nature. 

Treatment. For general hypertrichosis we can practi- 
cally do nothing. This, not because we cannot destroy hair 
so that it will not grow again, but because of the great 
amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for relief 
is that occurring upon the face in women. In 1879 Dr. 
Michel, of St. Louis, devised the method of removing the 
hairs in trichiasis by means of electrolysis, which was taken 



1 The Medical Eecord, 1881, xix. 281. 



HYPERTRICHOSIS. 259 

up by Dr. Harclaway, of the same city, for the removal of 
superfluous hair. The question is often asked : "Is the 
removal, by this method, permanent? " This question may 
be answered, " It is, without a shadow of a doubt." The 
object being to destroy the papilla, and that being very 
small and often placed at an unexpected angle to the sur- 
face of the skin, it is not possible always to accomplish this 
at the first attempt. But with patience and the necessary 
skill, it will finally be permanently destroyed. At times, 
after the dark coarse hairs have been removed, there will be 
found a number of finer and lighter hairs. This appear- 
ance is due partly to the uncovering of these hairs, and 
partly, it may be, to lanugo hairs becoming stronger under 
the stimulation of the operation. In most cases, with 
proper care and the use of a fine needle, the amount of scar- 
ring will be very slight, amounting to nothing more than fine 
punctate cicatricial spots. In some peculiarly irritable skins 
it is very difficult to prevent the formation of plainly visible 
scars. If the proper conditions are not observed, the oper- 
ator must expect to produce a good deal of disfigurement. 

The amount of pain experienced by the patient will vary 
greatly. Certain parts of the face are far more sensitive 
than others. On the whole, the pain does not amount to 
much. After a time the skin seems to become tolerant of 
the action of the current and the patient no longer com- 
plains. Hyper-pigmentation may be produced by the oper- 
ation. This is a very rare complication, and is only men- 
tioned by way of warning. 

Fig. 25. 




Epilating forceps. 

The instruments needed for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, a sponge electrode, 
a proper needle-holder, a fine needle, a pair of epilating for- 
ceps, and, if the operator's eyes are not good, a lens of low 



260 DISEASES OF T&E SKIN". 

power. Any sponge electrode will answer. There are 
various patterns of needle-holders, any one of which may 
be used. It should be long enough to be held with ease, 
and not too long to be readily manipulated. The most 
essential instrument is the needle. Hardaway recommends 
a needle made of iridium and platinum. He claims that it 
will follow the direction of the hair follicle, and more surely 
hit the papilla than will a steel needle. I have had most 
satisfactory results with a jeweller's instrument called a 
44 steel broach." These come in many grades ; those known 
as Nos. 5 and 7 are serviceable ones. A lens is generally 
not needed. Dr. Piffard has invented a needle-holder with 
lens attachment, which he has found useful. A galvan- 
ometer is not essential, but very desirable. 

A good light is necessary for the operation, and a cloudy 
day is a bad one for working. An operating or reclining 
chair is a comfort, and the patient should be so placed that 
the part to be operated on is on a level with the operator's 
eye. The operation is done in the following manner : The 
patient, being in position, is to be given the sponge elec- 
trode attached to the positive pole of the battery, and told 
to hold it in one hand. The hair to be extracted is then 
seized with the forceps, and put slightly on the stretch in 
the direction in which it naturally grows. The needle, 
attached to the negative pole, is then inserted parallel with 
the hair and into the follicle. One soon learns to know 
whether the follicle is entered or not by the sense of touch. 
When the follicle is entered the needle glides along 
smoothly ; when it is not entered a sense of resistance is 
communicated to the fingers as the skin is punctured. The 
depth to which the needle is to be thrust will vary with the 
case. Roughly speaking, it is from y 1 ^ to ^ of an inch. 
The needle being inserted, the patient is told to place the 
palm of the disengaged hand over the sponge electrode. In 
a few moments there will be frothing about the needle, and 
in from half a minute to a minute or more, the hair will 
come away upon the very slightest traction. The hand is 
to be removed from the sponge before the needle is taken 
out. 



ICHTHYOSIS. 261 

The hair must not be pulled on with any force, for the 
ease with which it leaves the follicle is a guarantee of the 
completeness of the operation. The hairs must not be 
extracted in close proximity, because the inflammatory action 
thus set up will lead to more or less deep ulceration and sub- 
sequent prominent scars. It is best only to extract the 
coarser hair and to leave the lanugo hairs alone. The 
strength of the current to be used will depend upon the 
quality of the patient's skin and the recentness of the filling 
of the battery. Eight cells are the fewest I have used and 
fifteen the greatest number. More exactly, a current 
strength of J to 1 J milliamperes. 

The patient should be directed to bathe the face in hot 
water and to anoint it with cold cream several times during 
the day following the operation. 

Hypohidrosis. See Anidrosis. 
Hystricismus. See Ichthyosis. 

Ichthyosis (I 2 k-thi 2 -o'si 2 s). Synonyms : Xeroderma ; 
Xeroderma ichthyoides ; Ichthyosis vera, seu congenita ; 
Sauriasis; (Fr.) Ichthyose ; (Grer.) Fischschuppenausschlag ; 
Fish-skin disease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, and 
scaling of the' skin, and sometimes by the development of 
warty -looking growths. 

Symptoms. Though the disease is congenital it usually 
does not show itself until after the second month, and some- 
times not until the second year. There are four varieties 
of the disease, namely : xeroderma, ichthyosis simplex, 
ichthyosis hystrix, and ichthyosis congenita. 

Xeroderma is the mildest grade of the disease. The skin 
is dry, harsh, slightly scaly, grayish or dirty-looking, and 
its natural lines are more pronounced than usual. Upon 
the extensor surfaces of the limbs it is particularly marked, 
and here too it is accompanied by keratosis pilaris It is 
most annoving to voung women who want to wear short- 
sleeved dresses. It is doubtless far more common than 
statistics show, as it very often is very slight in amount. 



262 



DISEASES OF THE SKIN. 



Ichthyosis simplex. This is a more severe grade of the 
disease in which the skin is dry, harsh, and scaly, and also 
divided off into small diamond-shaped or polygonal figures. 
(Fig. 26.) While the whole cutaneous surface may be 



Fig. 26. 




Ichthyosis. 

involved, the disease is usually most pronounced upon the 
extensor surfaces of the legs and arms, and the face, scalp, 
palms, and soles are often spared. The skin about the ex- 
tensor surfaces of the elbows and knees is generally thrown 



ICHTHYOSIS. 263 

into well-marked folds, while the flexor surfaces of the same 
joints are unaffected, the skin in these situations being soft 
and natural. While upon the extremities the disease is 
well developed, upon the trunk it may assume more of the 
xerodermatous form. When the face and scalp are affected 
they are simply very scaly, while on the palms and soles 
we have accentuation of the normal lines. In a typical case 
the skin, especially of the extremities, will be grayish, 
greenish, or blackish-green in color, dry, and the little 
polygonal plates will be attached in their centres and turned 
up slightly at their edges, so that they appear depressed in 
the centre. The amount of loose scaling is sometimes 
abundant, but usually moderate in amount. The hair, if 
the scalp is involved, is dry. The nails are often pitted. 
Ectropion may result in those rare cases in which the disease 
affects the face severely. Itching is often complained of, 
and eczema may complicate matters. There is a marked 
absence of perspiration, and lessened sebaceous secretion ; 
and the patients are sensitive to cold. The disease is 
usually worse in cold weather. 

Ichthyosis hystrix is one of the rarest forms of the dis- 
ease. It is never general, but confined to a limited area, 
or to a number of areas. It is often unilateral, and at 
times seems to follow the course of a nerve in its distribu- 
tion. It occurs in the form of horny papillary growths, 
that may be isolated and pinpoint-sized; or massed together 
into elevated, warty, dark-green plates, traversed by deep 
lines ; or arranged in long lines of parallel rows. When in 
the last form it has been called nerve nsevus, ngevus verru- 
cosus, neuropathic papilloma, papilloma neuroticum, and 
the like. Ichthyosis hystrix may be present alone, the rest 
of the skin being normal, or it may occur as a part of 
ichthyosis simplex. 

Ichthyosis congenita is the most rare form of the disease. 
It is also called Keratoma follicularis, Keratosis diffusa, seu 
epidermica, seu intra-uterina, and the u Harlequin foetus." 
It is considered by some to be a general seborrhoea It is 
present at birth, the skin being covered with fatty epidermic 
plates cracked in all directions and arranged transversely to 



264 DISEASES OF THE SKIN. 

the axis of the body. The fissures may extend into the 
corium. The eyes are held partly open, or there may be 
ectropion ; the lips cannot be moved ; and the feet are con- 
tracted and deformed. The color is yellowish-white or 
grayish. The scrotum and penis may not be involved. 
These infants are either born dead or survive birth but a 
short time. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks red, 
glazed, and dry, and then soon assumes the characteristics 
of ichthyosis simplex. 

With the exception of ichthyosis congenita, the disease 
does not show itself until some months after birth, but by 
the second year it has made its appearance. As a rule, it 
increases in severity as the patient grows older until adult 
age, when it usually remains stationary, or perhaps improves 
a little. It is a chronic disease and shows no tendency to 
get well. It does not seem to affect the patient's health, 
and it should be regarded rather as a deformity than a dis- 
ease. Occasionally mental weakness and other congenital 
defects have been noticed. 

Etiology. We know of no cause for the disease beyond 
heredity, which may be direct, skip a generation, or be 
through a lateral branch. Many cases occur without mani- 
fest heredity. It attacks both sexes about equally. It shows 
a tendency to occur in only one sex in certain families, 
while in other families both sexes are equally affected. 
It is a congenital defect in the development of the skin with 
a disturbance of the functions of perspiration and sebaceous 
secretion. 

Diagnosis. The disease is so unique that if its charac- 
teristics are remembered there can be no difficulty in diag- 
nosis. There is no other disease commencing in infancy 
that at all corresponds to ichthyosis simplex. Xeroderma 
may resemble a mild grade of squamous eczema, but has 
not its history. Sometimes we meet with a dry skin that 
is not ichthyosis, but it is only a passing state and has not 
existed from infancy. Ichthyosis hystrix may resemble 
common warts, and sometimes the latter may be present, 



IMPETIGO. 265 

but differs from them in its color and distribution. Ichthy- 
osis congenita differs from seborrhoea in not being removable 
by soaking in oil ; and by proving fatal. 

Treatment. The treatment is largely palliative. The 
free use of Russian baths or of prolonged warm baths, simple 
or with soda, and washing with soap, followed by inunctions 
of vaseline, glycerin, lanolin, or oil, such as cocoa butter, will 
keep the skin supple. Kaposi recommends a 5 per cent, 
naphthol ointment, or a 2 per cent, solution in spiritus sapo. 
viridis, or cod-liver oil, in conjunction with naphthol soap. 
Andeer 1 recommends a 3 to 20 per cent, ointment of resorcin 
well rubbed in, and covered with a bandage, and claims a 
cure in eight days. Sulphur ointment has also been recom- 
mended. Whatever is used must be persisted in. Ichthy- 
osis hystrix may be removed by curetting, or by salicylic 
acid plaster, 20 per cent, strength ; or by the same drug in 
alcohol or collodion, a drachm to the ounce. 

Besnier recommends as adjuvants to the local treatment, 
regular gymnastic exercise, and the internal administration 
of cod-liver oil. 

Prognosis. The prognosis is good as to life, bad as to 
cure. Thus far it has proved incurable in the hands of 
most physicians. All one can hope to accomplish is to 
render the patient comfortable and fit to mingle with his 
kind by repeated courses of emollient baths. Ichthyosis 
congenita is fatal in a few days, if the child is not born 
dead, as is usually the case. 

Ichthyosis Follicularis. See Keratosis follicularis. 
Ichthyosis Sebacea. See Seborrhoea sicca. 
Idrosis. See Hyperidrosis. 
Ignis Sacer. See Zoster. 

Impetigo (Pm-peH-i'go) is a name applied at one time 
to all pustular eruptions. At the present time there are 
but three varieties described, namely : Impetigo or impetigo 
simplex ; Impetigo contagiosa ; and Impetigo herpetiformis. 
The right of the first named variety to be recognized as a 

1 Monatshefte f. prakt. Dermat, 1884, iii. 365. 
12 



266 DISEASES OF THE SKIN. 

distinct affection is denied by systematic writers of all 
nations but our own. Our own writers largely follow Duhr- 
ing in their description of the disease, and as soon as they 
vary from his description, it seems to me that, instead of 
simple impetigo, they describe the contagious form. I shall 
here follow Duhring. 

Symptoms. Impetigo simplex. The appearance of the 
disease may or may not be preceded by loss of appetite, 
constipation, or malaise. The eruption consists of one to a 
dozen or more pustules that are pustules from the beginning. 
They are split-pea to finger-nail in size ; rounded : and raised 
above the surface of the skin. They have thick walls, a 
more or less marked areola, little surrounding infiltration, 
and no central depression. Their color is yellowish or 
whitish. They manifest no disposition to rupture, are dis- 
crete and disseminated, and do not incline to coalesce. 
While they may occur anywhere they are seated by prefer- 
ence on the face, hands, feet, and lower extremities. Itching 
and burning are absent, as a rule. The course of the dis- 
ease is acute, its duration being several weeks. The pustules 
gradually undergo absorption and dry into a crust, or they 
may be ruptured by external injury. The crust when it 
falls leaves a reddish base without pigmentation or scar. 
It is not contagious, and occurs mostly in children. 

Such is the disease as described by Duhring, It will be 
seen by reading the next section that it bears a strong re- 
semblance to impetigo contagiosa. 

Impetigo Contagiosa. Synonyms : Porrigo contagiosa ; 
Impetigo parasitica. 

An acute, inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesico-pustules and bulla?. 

Symptoms. By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to be 
marked by slight febrile disturbances. These are very 
slight, and I have not satisfied myself as to their occurrence 
in the many cases that I have seen, except incidentally as 
part of some digestive disorder that may be present. The 
eruption consists of vesico-pustules that come out in crops. 



IMPETIGO. 267 

They are of various sizes, but average that of a split-pea. 
They are at first surrounded, in well-marked cases, with a 
red halo, which soon fades. They tend to increase slowly 
in size, and sometimes assume grotesque shapes. They are 
not fully distended, but flaccid, and not infrequently upon 
the hands will bear a strong resemblance to a burn of the 
second degree. If the covers of the vesicles or small bullae 
are not disturbed, their contents in a few days will dry up, 
and the vesico-pustule will change into a straw-yellow 
granular crust, which is placed superficially upon the skin 
with its edge somewhat detached, and, it may be, turned up. 
In fact, it looks "stuck on." When the crust is removed 
or falls of itself, there is exposed an erythematous spot, 
which in a short time will disappear and leave no trace of 
its existence. If the vesicles are torn by scratching, or if 
by any other means their covers are removed, we shall find 
very superficial losses of substance — a moist surface covered 
with a slight purulent secretion. Even this disappears and 
leaves no trace, passing through the erythematous stage in 
its course to recovery. Such are the appearances presented 
in the majority of cases. 

Besides this usual and typical form we meet with another 
and rarer variety, in which, instead of vesi co-pustules, there 
are large bullae. These may be several inches in their long 
diameter, are of irregular oval shape, not fully distended 
with fluid, and sometimes show a slight depression in their 
centres. Their contents are at first serous, but soon become 
sero-purulent. They seem to be longer preserved than the 
vesicles, but otherwise run the same course. At first they 
have a slight zone of redness about them, but this soon dis- 
appears. They either are formed by two or more vesico- 
pustules running together, or spring up of themselves. 
They may attain their full size at once, or increase slowly. 
Rarely do they exist alone ; generally the typical vesico- 
pustules will be found in their neighborhood or elsewhere 
on the body. It is the bullous form that is liable to be mis- 
taken for pemphigus. 

Impetigo contagiosa is located principally upon the face, 
most often on the chin, and on the hands ; it may also occur 



268 DISEASES OF THE SKIN". 

upon the scalp, legs, and trunk, especially in infants. Ac- 
cording to my experience, the bullous form is most often 
seen upon the trunk. The lesions of both varieties are dis- 
crete ; exceptionally two or more may run together. They 
are superficial, and rarely very numerous. The bullous 
lesions are generally widely separated from one another. 
The disease does not run any definite course, and may last 
several weeks ; a slight amount of itching is sometimes 
present. 

Etiology. It is, as its name indicates, very contagious, 
and often occurs in epidemics. When one case is met with 
in dispensary service, several more may be expected in 
children of the same family or neighborhood. It is readily 
inoculable both on the subject of the disease and on others. 
Not unfrequently we see a mother or other attendant of a 
child with the characteristic lesions of impetigo contagiosa 
upon the arms, derived from carrying the child suffering 
with the same disorder. What the contagious element may 
be is not yet determined with certainty, though various 
investigators have described several parasites as the cause of 
the disease. We know that all pus is under certain circum- 
stances inoculable, and hence it has been maintained that 
there is no such disease, properly speaking, as contagious 
impetigo. But when we succeed in inoculating from an 
ordinary impetigo pustule, we produce an ordinary impetigo 
pustule, not the characteristic vesico-pustule of impetigo 
contagiosa. It has been stated by some authorities that the 
disease is due to lice on the head. In some cases phtheiria- 
sis capitis may be present, because both diseases occur with 
special frequence in children of the poor. In my own 
experience, in most cases no such relationship could be 
traced. A number of cases have been reported of the occur- 
rence of contagious impetigo shortly after the fall of vaccine 
crusts, and thus has been suggested the possible connection 
between impetigo and vaccinia. It is more frequent in the 
warm months than in the cold. Children furnish the vast 
majority of the cases. 

Diagnosis. Impetigo contagiosa is diagnosticated by 
the presence of discrete, partially distended vesico-pustules, 



IMPETIGO. 269 

which are located upon the exposed parts — head, face, and 
hands — in most cases ; these are sometimes grouped, run 
an acute course, and dry up into straw-yellow " stuck-on" 
crusts. It is sometimes preceded by slight constitutional 
disturbances, and accompanied by a slight amount of itching. 
It must be differentiated from simple impetigo, pustular 
eczema, varicella, scabies, pemphigus, and possibly ecthyma. 

The lesions of simple impetigo are pustules from the start, 
while those of impetigo contagiosa are first vesicles and then 
vesico-pustules. The pustules of impetigo are prominently 
raised, and run no definite course. The vesico-pustules of 
impetigo contagiosa are flattened, and run a rather definite 
course. The crusts of impetigo are generally greenish, 
while those of the contagious form are yellowish. Impetigo 
is not so readily inoculable as impetigo contagiosa, and is 
much more widely disseminated, as a rule. Simple impetigo 
is a deeper process than the contagious form. 

Pustular eczema is itchy ; its pustules tend to break 
down quickly, run together, and form large patches, which 
soon become covered with a greenish or blackish crust. 
These phenomena are entirely foreign to impetigo con- 
tagiosa. Eczema does not present vesico-pustules nor bullae, 
as a rule, and shows slight tendency to spontaneous re- 
covery. Varicella is an acute contagious disease, with con- 
stitutional symptoms in most cases. Its vesicles are smaller 
than those of impetigo contagiosa, and they run a definite 
course peculiar to themselves. They are widely distributed 
over the whole surface, usually appear first on the trunk, 
sometimes occur on the fauces, and not infrequently leave 
pitted scars. Contagious impetigo is in most cases limited 
to the exposed parts, it never occurs upon the fauces, and 
its lesions leave no trace. The crusts of varicella are small, 
while those of contagious impetigo are large. 

The diagnosis from scabies offers little difficulty. In 
fact, the location of both diseases upon the back of the 
hands is their strongest point of resemblance. When we 
bear in mind that scabies is very itchy, that it occurs 
usually as a copious eruption upon the hands, wrists, and 
forearms, about the umbilicus, on the nipples of females and 



270 



DISEASES OF THE SKIN. 



the genitals of males ; that scratched papules and pustular 
lesions are more characteristic of it than vesicles, and that 
it presents the pathognomonic furrows, we should not con- 
found it with impetigo contagiosa, which has none of these 
symptoms. Further, impetigo will, in almost all cases, occur 
upon the face at the same time with the hands, and that 
location is very rarely attacked by the itch mite. 

The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparent contagious qualities, were instances of this 
bullous form of impetigo. The diagnosis between the two 
diseases can scarcely be made with certainty by the appear- 
ances of the bullae alone ; we must also take into considera- 
tion the general course of the disease. The differential 
diagnosis may be given as follows : 



Pemphigus. 

1. Occurs chiefly in adults. 

2. No source of contagion can be 

found. 

3. No particular sites of pref- 

erence ; if anything, it is 
most frequent on the ex- 
tremities. 

4. Chronic in its course ; marked 

by frequent relapses ; may 
return from year to year. 

5. Bullae are fully distended with 

a clear fluid, so that their 
covers appear tense. They 
often spring up out of the 
sound skin without areola. 



6. Lesions often occur in great 

numbers, so as to cover the 
whole body, and at times are 
pruriginous. 

7. Disease obstinate to treatment, 

and prognosis usually grave. 



Impetigo Contagiosa. 
(Bullous form). 

1. Occurs chiefly in children. 

2. A source of contagion can 

usually be found. 

3. Met with most often upon the 

trunk ; sometimes it may 
occur on the face, hands, or 
extremities. 

4. Acute in its course, rarely 

lasting more than a few 
weeks. 

5. Bullae not fully distended, but 

flaccid, and contain sero- 
purulent fluid. They may 
have a well-marked red halo 
while slowly attaining their 
full size. Characteristic 
vesi co-pustules are generally 
present elsewhere at the 
same time. 

6. Lesions, few in number, do 

not involve the whole body, 
and itch but little, if at all. 

7. Disease yields readily to treat- 

ment; prognosis uniformly 
good. 



IMPETIGO HERPETIFORMIS. 271 

Ecthyma should not be mistaken for impetigo contagiosa. 
It occurs in broken-down subjects, affects by preference the 
lower extremities, is seen most often in adults, and its lesions 
are deep pustules, which are highly inflammatory and pain- 
ful. It is non-contagious, and inoculable with difficulty. 
These symptoms will sufficiently distinguish the two dis- 
eases. 

Prognosis. The prognosis of impetigo contagiosa is 
always good ; so readily is it cured that the patients seldom 
present themselves a third time at the dispensary. 

Treatment. The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm Avater 
and soap, and covered with a 5 per cent, carbolized vaseline, 
or with oxide of zinc ointment with carbolic acid in the same 
strength, or with the ointment of the ammoniate of mercury 
diluted to half its strength. If there is a good deal of crust- 
ing, the crusts may readily be removed by soaking them 
with oil or hot water, after which the applications men- 
tioned may be made, or a very mild mercurial ointment 
used. In the bullous form it is well to prick the bullae at 
their most dependent part, and let the fluid escape, after 
which the lesions may be treated as just indicated. 

Impetigo Granulata. See Pediculosis. 

Impetigo Herpetiformis. This disease was first described 
by Hebra 1 in 1872. 

In this country it is exceedingly rare, only one case 
having been reported. We owe to Hebra and Kaposi 
nearly all we know about the disease, and it is from Kaposi 2 
that the account here given is taken. 

The disease begins with an eruption of pustules in the 
genito- crural region, about the umbilicus, on the breasts, 
and in the axillae ; later upon various other locations. The 
pustules are crowded together, grouped, pinhead-size, with 
at first opaque, and later greenish-yellow contents. They 
dry into a dirty-brown crust, while immediately around 
them new pustules appear in double or threefold circles, 

1 Wiener med. Wochenschrift, 1872, No. 48. 

2 Pathologie unci Therapie der Hautkrankheiten. 



272 DISEASES OF THE SKIN. 

by the drying of which the crust is enlarged. The disease 
spreads by the growth of the individual groups and by the 
coalescence of neighboring ones. Underneath the crusts 
the skin appears red and covered with new epidermis ; or 
deprived of epidermis, moist, infiltrated, and smooth; or 
papillary, but never ulcerated. Within three or four months 
nearly the whole skin is involved, swollen, hot, covered with 
crusts, showing torn and excoriated places with here and 
there circles of pustules. The mucous membrane of the 
tongue may show circumscribed, gray patches. There is a 
continuous remittent fever, and each outbreak of pustules is 
marked by chills, higher fever, and dry tongue. Nearly 
all cases prove fatal. The disease has affected almost ex- 
clusively pregnant women, only one man having been re- 
ported with the malady. Delivery has not stopped the 
course of the disease. It is probably of septic origin. 

Diagnosis. The disease is held by Kaposi to differ 
from dermatitis herpetiformis in being only pustular ; in 
its peculiar location and manner of spreading ; in the ab- 
sence of itching ; in the severe constitutional symptoms ; 
and in its lethal ending. 

Treatment. No treatment has proved successful. We 
can only do our best to nourish the patient ; and by means 
of baths, dusting-powders, or alkaline lotions render her as 
comfortable as possible. 

Induratio Telae Cellulosse Neonatorum. See Sclerema 
neonatorum. 

Inflammatory Fungoid Neoplasm. See Mycosis fungoide. 

Intertrigo. See Erythema intertrigo. 

Iodine Acne. See Dermatitis medicamentosa. 

Itch. See Scabies. 

Juckblattern. See Prurigo. 

Kahlheit. See Alopecia. 

Kelis. See Keloid. 

Keloid (Kel'oid). Synonyms : Kelis ; (Fr.) Cancer 
tubereux, Cheloide ; (Ger.) Knollenkrebs. 

A connective-tissue new-growth in the skin, occurring 



KELOID. 



273 



most commonly upon the chest ; characterized by hardness, 
by a pinkish color, and by sending off prolongations in all 
directions. (Fig. 27.) 

Symptoms. It is usual to divide keloids into two varie- 
ties, one of which is called the true or spontaneous keloid, 



Fig. 27. 






Keloid. (After Taylor.) 

and the other the false or secondary keloid the result of 
injuries. Of late the opinion is gaining ground that no 
such distinction can be made. As most commonly met with 
it consists in a single, firm, hard, pinkish, freely movable, 
oval or elongated, elevated tumor upon the upper half of 

12* 



274 DISEASES OF THE SKIN. 

the sternum, from which claw-like processes are given off in 
all directions. While there may be but one tumor, the 
lesions may be multiple, there being either one large and 
several small ones upon the chest, or many scattered over 
the body. They begin as small, pinkish elevations and 
gradually enlarge until they attain a certain size, when they 
may remain stationary, or else slowly grow. They assume 
all sorts of shapes and sizes. Sometimes they have an 
even surface, sometimes they are nodular. They may be 
quite small, or they may be so large as to run nearly half- 
way across the chest Then the appearance is as if the 
skin were drawn up into the tumor. The epidermis is 
smooth over them, and the pink color is due to the dilated 
bloodvessels. Sometimes the color is white. Though they 
are rarely met with on the face in the white races, they are 
very common upon the face of negroes. They are often 
attended by a good deal of pain, or pruritus, or pricking 
sensations. 

Besides this form of keloid, that may or may not be spon- 
taneous, we have the evident scar keloid that occurs over the 
site of an injury to the skin. These have followed syphilides 
that have destroyed the skin, variola pustules, psoriasis, a 
blister, or acne. 1 They may be limited to the site of the 
previous lesion, or spread beyond it. This form of keloid is 
very often seen on the face of the male negro who shaves, 
the cheeks and chin being studded over with small, hard, 
white elevations. The hypertropliied scar resembles keloid, 
but never spreads beyond the limits of the injury, has no 
claw-like processes, is not so pinkish, nor so permanent. 

Etiology. We know scarcely anything as to the cause 
of keloid, and can only beg the question by saying that it 
is a predisposition on the part of the skin. It is probable 
that some minute injury precedes the tumor. The negro 
race is peculiarly prone to the disease. Sex is without 
influence, and it may occur at any age, though rare before 
puberty and in old age. 

Treatment. As a rule it is safest to leave the growths 

1 Purdon : Joura. Cutan. and Ven. Dis., 1882-3, i. 203. 



KERATOSIS FOLLICULARIS. 275 

alone. Cutting them out is often disappointing in its results, 
as the growth is apt to return. Multiple scarifications fol- 
lowed by the application of acetic acid have been successful. 
Leloir and Vidal 1 recommend following multiple scarifica- 
tions with a boric acid dressing. The next day mercurial 
plaster is to be applied, and changed every morning and 
evening. Perseverance in this method, they say, may result 
in a cure. Compression by means of an elastic bandage has 
been recommended. Hardaway has succeeded in removing 
one keloid and two hypertrophied scars by means of electro- 
lysis, and Brocq has commended the method. A stout 
needle must be used and multiple punctures made in all 
directions, and in the tissues for a space beyond the tumor. 
Andeer 2 recommends resorcin and a bandage. Hypoder- 
matic injections of morphia, or the application of belladonna 
ointment, may be necessary to relieve pain. 

Prognosis. It is possible for keloids to undergo spon- 
taneous involution. This is especially the case in the scar 
keloid following syphilis. Usually this cannot be expected. 

Keloid of Addison. See Morphoea. 

Keloid of Alibert. See Keloid. 

Keratodermies Palmaires et Plantaires. See Callositas. 

Keratoma Palmaris et Plantaris. See Callositas. 

Keratosis Circumscripta. See Ichthyosis. 

Keratosis Diffusa seu Epidermica. See Ichthyosis con- 
genita. 

Keratosis Follicularis (Ke 2 r-a 2 t-os'i 2 s fo 2 l-i 2 kV-la 3 ris). 
This is a rare affection of the skin to which especial atten- 
tion has of late been given. It is probably the same as was 
described by Guibout by the name of acne sebacee cornee, 
and by Lesser as ichthyosis follicularis. The French have 
named it psorospermose folliculaire vegetante, but as this 
title was given it by Darier and Thibault in 1889 under 
the idea that it was due to psorosperms, a pathological basis 

1 Annal. Derm, et Sypli , 1890, No. 3. 

2 Centralbl. f. med. Wissenscliaft, 1888, xxvi., 785. 



276 DISEASES OF THE SKIN. 

that is not yet proven, and as Morrow 1 had already reported 
a case in 1886, with the title of keratosis follicularis, and 
White 2 another in 1889, under the same title, it seems to 
me best to retain their title. 

Symptoms. The disease affects nearly the whole cuta- 
neous surface, though both in Morrow's and White's cases 
the palms and soles were free. The parts most affected are 
the scalp, face, sternum, flanks, and groins. The eruption 
begins as pinhead-sized papules, which are firm and of the 
color of the skin. As they increase in size they become 
hyperaemic ; still growing, they become hemispherical or flat- 
tened, with smooth or polished, dense adherent coverings of 
nail-like consistence, and varying in color from dull red to 
purplish, dusky red, brown, and brownish black. Some of 
them are excoriated by scratching and bear hemorrhagic 
crusts. These lesions are discrete, and the skin about them 
normal. They are located in the hair follicles. In places 
the lesions run together and form elevated areas with uneven 
surfaces and covered by thick yellowish or brownish, flat- 
tened horny concretions; or there may be brownish or 
blackish plates. The patches feel rough and somewhat 
greasy. Here and there will be found papillomatous excres- 
cences ; or enormously dilated follicular openings filled by 
comedo-like, firm, slightly projecting concretions forming 
hemispherical elevations, which when expressed are found 
to be hard and perfectly dry, leaving the follicle mouth 
patulous. The nails are coarse, slightly thickened, and 
jagged at their free edges. Boeck 3 says that they are often 
the seat of a marked hyperkeratosis without a trace of the 
disease itself anywhere in their neighborhood. The hard 
palate in White's case showed some follicular elevations. 
Pruritus is marked in some cases. A fetid odor is given 
off from the patient. 

Upon the scalp the disease appears for a long time as a 
seborrhoea sicca, but later the same elevations about the 

1 Journ. Cutan. and Ven. Dis., 1886, iv. 257. 

2 Journ. Cutan. and Gen.-urin. Dis, 1889, vii. 201. 

3 Archiv. f. Derm, und Syph., 1891, xxiii. 857. 



KERATOSIS FOLLICULARIS, 277 

hairs can be made out as are seen upon the general integu- 
ment. Upon the backs of the hands and fingers the erup- 
tion presents the appearance of simple papillary growths, 
little pale-white, slightly raised, confluent and adherent 
masses. Upon the palms and soles, instead of elevations, we 
find punctate depressions, and perhaps a hyperkeratosis. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. It 
seems to have no damaging effect on the health. It affects 
specially the scalp, axillae, inguinal region, abdomen below 
the umbilicus, backs of the hands and feet, and the wrists. 

Etiology. We know nothing positive about the etiology 
of this rare affection. White met with it in a father and 
daughter, and that would suggest the idea of heredity. 

The psorosperm of Darier is regarded by some as simply 
a changed epithelial cell, and of no importance as an etio- 
logical factor. Darier and many other competent observers 
hold that it is a true parasite, and the cause of the disease. 
The disease may begin at any age, cases having been reported 
as commencing in the first weeks of life, in the sixth, six- 
teenth, twenty-second, twenty-seventh, and thirty-sixth year. 

Pathology. Bowen, who made a careful examination of 
White's first case, says that u the disease is a keratosis of the 
epithelial lining of the mouths of the follicles, which, by 
extension downward, gradually produces pouch-like depres- 
sions in the corium. The capacity for corneous metamor- 
phosis is so great that the central portion becomes a firm 
horn, which, by production of horny matter from below, is 
gradually pushed out above the surface of the skin. There 
was no proof that the sebaceous glands were affected by the 
horny change." Robinson found in Morrow's case that the 
changes occurred principally in the sebaceous glands. But 
the disease has not yet been sufficiently studied to warrant 
positive statements. The psorosperm is described as a sin- 
gle-celled organism, which is round, generally encysted, and 
contained in the epithelial cell. 

Diagnosis. The disease, according to Lustgarten, 1 dif- 

1 Journ. Cutan. and Gen.-urin. Dis., 1891, ix. 7. 



278 DISEASES OF THE SKIN". 

fers from pityriasis rubra pilaris in lacking the constant 
and early involvement of the palms and soles, and the 
extensive, diffused, scaly dermatitis of the face, neck, and 
other parts. 

Treatment. The proper treatment is yet undeter- 
mined. It might be well to try the methods found useful in 
ichthyosis. 

Keratosis Pigmentosa. See Verruca senilis. 

Keratosis Pilaris (K. Pil-a'riY). Synonyms : Lichen 
pilaris ; Pityriasis pilaris ; Ichthosis seu hyperkeratosis follic- 
ularis ; Cacotrophia folliculorum ; (Fr.) Xerodermic pilaire, 
Ichthyose anserine des scrofuleux. 

Symptoms. As its name indicates, this is a disorder of 
cornification. It is characterized by a heaping up of the 
corneous cells about the mouths of the hair follicles in the 
form of small conical, whitish or grayish elevations. Be- 
tween them the texture of the skin is normal ; its color 
may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of the 
limbs, especially upon the upper arm and thigh, but may 
occur anywhere. The appearance of the affected part re- 
sembles cutis anserina, being dotted over with little pinhead 
to small-pea-sized papules, each one of which is either 
pierced by a hair or has a black dot at its summit indicat- 
ing the mouth of the hair follicle. The papules are often 
scaly. The hair is either normal, broken off, or only to be 
found by opening the papule, when it will be seen curled up 
inside of it. The skin feels dry and harsh. There may 
be slight pruritus. Pityriasis capitis may be present at the 
same time. As the disease is attended by but slight, if any, 
subjective symptoms it is often overlooked. It is a chronic 
affection in most cases. 

Brocq describes a Keratosis pilaris of the face beginning as 
minute scaly papules about the hairs, which crowd together 
to form patches and give a rosy or red tint to the skin. 
After a time the disease seems to destrov the follicle, and 
we find depressed scars arranged in rows or scattered about 
on the red patch. This bears some resemblance to lupus 



KERION. 279 

erythematosus, and is the ulerythema ophryogenes of Taenzer. 
Besnier describes a somewhat similar condition as occurring 
upon the extremities. 

Etiology. The disease is sometimes congenital and often 
forms a part of ichthyosis. It is most common in women, 
and in those who do not bathe frequently, or in whom there 
is cutaneous inactivity. 

Diagnosis. It differs from cutis anserina in being a 
permanent condition ; from the miliary papular sypliilide 
in being whitish, grayish, or blackish, and not dark-red or 
raw-ham color, and in being removable by soap and water. 
Lichen scrofulosorum occurs in strumous subjects and in 
well-marked circular or crescentic patches, which is foreign 
to keratosis. Papular eczema differs in being very itchy 
and in having red inflammatory lesions. Ichthyosis is a 
general affection of congenital origin, and with peculiar 
markings of the skin, not being limited to the hair follicles. 

Treatment. The vigorous use of green soap and water 
in an alkaline bath, followed by oil or vaseline, will remove 
the evidences of the disease. Vapor or Russian baths may 
be used for the same purpose. As the affection is allied to 
ichthyosis it may be treated on the same plan, a new course 
of bathing being taken with each relapse. 

Keratosis Senilis. See Verruca senilis. 

Kerion (Ke'-ri 2 -o'n). Synonyms : Trichomykosis capil- 
litii ; Tinea kerion ; Kerion Celsi. 

Symptoms. This is a more or less chronic inflammation of 
the scalp or beard that most often is a form of ringworm ; but 
it may be produced quite independently of that disease. The 
affected part becomes red, cedematous, swollen, and boggy, 
and may assume a purplish color. Its surface is glazed, 
uneven, and studded with a number of yellowish suppurat- 
ing points, or with foramina out of which oozes a sticky, 
viscid, gelatinous, transparent fluid. Sometimes suppura- 
tion may occur attended with a sero-purulent discharge. 
The swelling is round or oval in shape, and varies in size ; 
it may be but one or two inches in diameter or as large as 
a turkey's egg. The pustules form about the hair in the 



280 DISEASES OF THE SKIN". 

early stage ; later the hairs fall and the discharge takes 
place from the openings of the hair follicles. If the tumor is 
opened a thick viscid material is discharged. If the disease 
occurs with ringworm, the hair will be broken off. Per- 
manent baldness may result if the inflammation is intense. 
There is more or less pain and tenderness, and at times 
itching and burning. The posterior cervical glands may be 
enlarged. 

Etiology. The disease is comparatively rare. It occurs 
chiefly in children of poor constitution. It is most com- 
monly due to the trichophyton fungus passing deep down 
into the hair follicles, but may be caused by the application 
of irritants to the scalp, or follow eczema, favus, or sycosis 
of that part. 

Diagnosis. Kerion must be diagnosticated from abscess, 
a papilloma, a gumma, and a sebaceous cyst. An abscess is 
not preceded by ringworm, has no history of an irritant 
applied to the scalp, and may arise without any antecedent 
disease of the scalp ; it is more painful ; it is often accom- 
panied by a sensation of throbbing, by chilliness, fever, and 
general malaise; when fully formed there is fluctuation, and 
when opened it gives exit to pus. These symptoms are not 
met with in kerion. A papilloma is non-inflammatory, 
firm to the touch, and is unaccompanied by a discharge. A 
gumma is usually accompanied by other signs of syphilis, 
and tends to break down and ulcerate. A sebaceous cyst is 
slow in its growth, the skin over it is normal, there is no dis- 
charge, and when opened it gives vent to a cheesy mass. A 
fatty tumor is a chronic, elastic, freely movable swelling, 
with normal skin over it. 

Treatment. In treating a case epilation should be per- 
formed in order to save the hair and give exit to the dis- 
charge. If some irritant application is the cause, that 
should be discontinued, and hot-water dressings, antiseptic 
solutions, or mild emollient applications employed. If the 
cause is ringworm the remedies proper for that disease 
should at once be used. What they are will be found under 
Trichophytosis capitis. 






Kleienflechte. See Chromophytosis. 






•LENTIGO. 281 

Kohlenbeule. See Carbuncle. 
Kopskurv. See Favus. 
Knollenkrebs. See Keloid. 
Kratze. See Scabies. 

Kraurosis (Kra*-ro'-si 2 s) Vulvae is a name proposed by 
Breisky 1 for a form of atropby of tbe skin of the external 
genitals of women. The disease has its seat in the vestibule, 
the labia minora with the frenulum and praeputium clitoridis, 
the inner surfaces of the labia majora up to the posterior 
commissure, and the contiguous skin of the perineum. It 
gives rise to the appearance of a defect in the development 
of the normal folds of the vulva. At times the labia minora 
and the praeputium clitoridis are apparently wanting. The 
affected skin is white and dry, the epidermis is often thick- 
ened, and telangiectasic vessels are visible. Stenosis of the 
vulvar entrance may result, and thus obstruction be offered 
both to coitus and parturition. The cause is obscure ; pos- 
sibly a long-continued blennorrhea, or a congenital defect, 
or a process analogous to leucoplakia buccalis. Treatment 
is of no effect. 2 

Krebs is the German for cancer. 
Kupferfinne. See Rosacea. 
Kupfriges Gesicht. See Rosacea. 
Kupferrose. See Rosacea. 
Land Scurvy. See Purpura hemorrhagica. 
Lausesucht. See Pediculosis. 
Leichdorn. See Clavus. 
Leiomyoma Cutis. See Myoma. 

Lentigo (Le 2 nt-i'go). Synonyms: Ephelides ; (Ger.) 
Sommersprossen, Linsenflecke ; Freckles. 

Freckles are properly a species of chloasma. They occur 
as light to dark brown or even black macules, and are 
usually located upon exposed parts, especially the face and 

1 Zeitschrift f. Heilkunde, 1885. 

2 Janovsky : Monatshefte f. prakt. Dermat, 1888, vii. 951. 



282 D I SEA'S IS S OF TIT-E SK1X. 

backs of the hands. In size they vary from a pinhead to 
a split-pea. They give rise to no subjective symptoms. 
They usually do not appear before the eighth year of life, 
but congenital cases have been reported. These should 
rather be classed among the pigmentary nsevi. A division 
is sometimes made between those which are permanent and 
occur upon unexposed places, and those which occur in 
summer to disappear in winter. To the former the name 
lentigo is given, and to the latter ephelides. The distinc- 
tion is not worth preserving. As old age is approached, 
freckles no longer form, and the old ones are apt to dis- 
appear. 

Etiology. The cause of freckles is probably an inborn 
peculiarity of the skin. It has been advanced as a theory 
of their production that they are due to the chemical action 
of the sun's rays upon the blood. Blonds are more prone 
to them than are brunettes. Many people never freckle. 
Symptomatically they occur as part of atrophoderma pig- 
mentosum. 

Pathology. Freckles are but circumscribed deposits of 
pigment. Cohn 1 has endeavored to show that lentigines 
differ from ephelides in being discrete, slightly elevated, and 
having their pigment in all the layers of the epidermis, as 
well as in the cutis, and in being associated with changes in 
the bloodvessels of the cutis ; while ephelides are crowded 
together, their pigment is only in the basal layer of the 
epidermis, and there are no changes in the bloodvessels. 

Treatment. The treatment of freckles is the same as 
that of chloasma. The only prevention is to protect the 
skin from the action of the sunlight. Hardaway recom- 
mends the following : 

R . Hydrarg. amnion., \ ~ . 4 ! 

Bismuthi subnitrat, J ' ' ^ J ' 

Ungt. aq. roste, 3J ; 30 M. 

He also speaks highly of electrolysis for the removal of 
very black freckles. There is hardly any use in endeavor- 

1 Monatshefte f. prakt. Dermat., 1891, xii. 119. 



LEPRA 



283 



in2 to cure freckles occurring from the action of the sun, as 
they depart of themselves. 

Leontiasis. See Leprosy. 

Lepothrix. See Tinea nodosa. 

Lepra (Le 2 p'ra s ). Synonyms : Elephantiasis Grnecorum ; 

Fig. 28. 










Tubercular and anaesthetic leprosy. 1 



1 From a photograph kindlv loaned me bv Dr. P. A. Morrow, of New 
York. 



284 DISEASES OF THE SKIN. 

Leontiasis ; Satyriasis ; Lepra Arabum ; (Fr.) La Lepre ; 
(Ger.) Der Aussatz ; (Norweg.) Spedalskhed ; Leprosy. 

A chronic, endemic, constitutional disease due to infection 
by a specific bacillus ; characterized by anaesthesia, erythe- 
matous patches, tubercles, ulcerations, atrophies, and de- 
formities according to the structures most affected ; and 
ending in death. (Fig. 28.) 

Symptoms It is usual to describe three forms of leprosy 
— the tubercular, the anaesthetic, and the mixed. This is 
convenient for clinical purposes, though not absolutely cor- 
rect, as even in the nearly pure tubercular form there is 
more or less anaesthesia. All forms exist in all endemic 
regions, but now one and now another form predominates. 
The tubercular form is the one most common in cold 
countries, the anaesthetic in hot countries. Morrow, 1 how- 
ever, found that in the Sandwich Islands the tubercular 
form constituted one-half of the cases, while the anaesthetic 
form formed but one-third of them. 

Tubercular leprosy. Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 
months before the disease frankly declares itself the patient 
is out of health. He feels indefinitely ill, depressed, and 
listless ; he has dyspepsia and diarrhoea ; he is weak, chilly, 
and suffers from profuse sweating. There may be nose- 
bleed. Then a remittent fever of malarial type appears. 
This fever may occur without the other prodromata, and 
may recur with each new outbreak of tubercles. After a 
time an erythematous eruption appears upon the face, ears, 
the forearms, and thighs. It consists of purplish or 
mahogany-red, slightly raised, hyperaesthetic, smooth, shiny 
patches, of one or several inches in diameter, usually of oval 
form. The eruption may fade entirely away, to again ap- 
pear with a fresh outbreak of fever. After some three to 
six months of the exanthem the tubercles appear, either 
upon the sites of the previous lesions, or quite indepen- 
dently of them. They begin as pinhead-sized pink papules 
that enlarge to split-pea or even to hen's-egg size, yellowish- 

1 New York Med. Journ., 1889, 1, 85. 



LEPRA. 285 

brown tubercles. If a number of these run together large 
infiltrated patches are formed of irregular shape and nodular 
surface. Then infiltrations may also arise by an increased 
deposit of leprous material in the macules, for the macules 
themselves are formed of leprous material and are not sim- 
ply erythematous lesions. Sometimes the infiltrated patches 
that arise from the macules may assume ring shapes, by 
clearing up in the centres. The tubercles are completely 
anaesthetic. They may come anywhere, but are most com- 
monly seen in the eyebrows, lobes of the ears, the face gen- 
erally, upon the extremities, breasts, scrotum, and penis. 
The scalp is said never to be affected. The mucous mem- 
branes of the mouth, nose, larynx, trachea, uterus, and 
vagina are also involved, as may be the conjunctivae. The 
tubercles may undergo spontaneous involution in one place, 
while fresh outbreaks of them occur in other places. Or 
they may soften and break down and form leprous ulcers, 
which are indolent, sharply defined, and glazed over with a 
mucous discharge of peculiar odor. These may attain enor- 
mous dimensions, becoming serpiginous and phagedenic. 
When these ulcers go deep, as they may do on the lower 
extremities especially, there may take place spontaneous 
amputation of the fingers, toes, or whole members. This is 
one form of mutilating leprosy, which is most frequently 
encountered in the anaesthetic form of the disease. Or the 
tubercles may, on disappearing, leave atrophic spots. Their 
development and involution are always slow. The appear- 
ance of a well-developed case is striking. The face is de- 
formed by the tubercles and assumes the "leonine'' expres- 
sion on account of the thickening of the eyebrows causing 
them to protrude so that the eyes are sunken and have a 
stern expression. The immense lobes of the ears hang 
down. The lips protrude and are often everted. Tubercles 
stud the face. The forearms are enlarged and knobby. 
The hands are deformed. There is very commonly a dis- 
charge from the nose, a disagreeable odor from the mouth, 
and the sense of smell is lost. The eyesight is often lost, 
the voice is cracked and croaking. The lymphatic glands 
are often swollen. Happily, both in men and women 



286 DISEASES OF THE SKIN". 

sterility is the rule. There is commonly atrophy of the 
testicles and loss of sexual power in men. The disease is 
steadily progressive, and death occurs in eight years, on an 
average, though the disease may last for many years. 
Crocker says 40 per cent, die of the disease itself, 40 per 
cent, die from renal or lung complications, and the rest from 
diarrhoea, anaemia, or general marasmus. 

Anoesthetic leprosy announces its onset not by febrile 
symptoms, but by shooting, lancinating pains in the chief 
nerve trunks, as the ulnar, median, peroneal, and saphenous. 
There are also pain and tenderness in various places, and a 
state of general hyperesthesia. There may also be symp- 
toms of general malaise and digestive disturbances. A 
frequent early symptom is a vesicular or bullous eruption 
upon the fingers and toes, with at first serous, then purulent 
contents. These may burst and leave a white, shining anaes- 
thetic spot, or an ulceration that heals with an anaesthetic 
cicatrix. Numbness soon follows the hyperaesthetic state. 
The patient cannot grasp things firmly, and the consequent 
unskilfulness of his actions may be the first thing to attract 
his attention. This shows muscular weakness as well as 
numbness. 

After some months of these prodromal symptoms an erup- 
tion of macules similar to those of the tubercular variety 
appear upon the extremities, face, and back. They are 
isolated, of oval shape, hardly raised above the surface, and 
of a pale yellow to reddish-brown color. These often enlarge 
peripherally and clear up or become atrophic in the centre. 
Sometimes instead of being oval they will take the form of 
wide streaks or of gyrate figures. They are often hyperaes- 
thetic when newly formed, but always perfectly anaesthetic 
when they have become atrophic, and even before that in 
cases that have lasted some little time. The large nerve 
trunks, as that of the ulnar, are at first hyperaesthetic, but 
later are anaesthetic and can be felt like a whip- cord, and 
rolled about under the finger without giving rise to pain. 
Anaesthetic areas will be found independently of the macules, 
and in old cases a rather general anaesthesia develops so that 
the patient burns himself without noticing it. The ances- 



LEPRA. 287 

thetic areas are subject to change from time to time. Soli- 
tary bullae appear from time to time as well as urticaria-like 
lesions. Marked atrophy of the muscles of the hands and 
feet occurs, and paralysis of the extensor muscles of the 
second and third phalangeal joints. Wasted interossei 
muscles, and permanent flexion of the last phalanges of the 
fingers give as characteristic an expression to the hand in 
this form of leprosy, as the tubercles do to the facial expres- 
sion of the tubercular form. After some ten years or so, 
during which the greater part of the cutaneous surfaces may 
have become studded over with white, wrinkled, hairless, 
atrophic spots, the permanent stage is reached. During 
these years painless amputation of many of the joints may 
have occurred by a process of dry gangrene (Lepra muti- 
lans). Erysipelas may occur. The nails and hair are shed. 
Sleeplessness may prove a distressing symptom. Loss of 
sexual power, and sterility, are manifest. This form lasts 
much longer than the tubercular form, fifteen years being an 
average duration. Sometimes a fair degree of health is 
preserved for a much greater length of time. In most all 
cases more or less hebetude of mind is marked, becoming 
more pronounced with the duration of the disease. 

The mixed form is a combination of the symptoms 
of the two former varieties, and perhaps is the one most 
commonly met with in this country. Indeed, it is the rule 
that all tubercular cases present certain symptoms of the 
anaesthetic form, and vice versa, the variety being named 
from the prevailing lesion. 

Etiology. Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by the 
sea-shore, eating of putrid fish, heredity ; but in the light 
of our present knowledge there is but one cause, and that is 
contagion. The limits of this book forbid full discussion of 
this interesting topic, but an incontrovertible argument for 
this view is found in the spread of the disease in the Sand- 
wich Islands, where, within a few years of its introduction, it 
has decimated the community. For further evidence upon 
this point the reader is referred to the excellent papers by 
Dr. P. A. Morrow which have appeared in a number of 



288 DISEASES OF THE SKIN. 

American medical journals during 1890. The contagious- 
ness of the disease is a strong plea for the segregation of the 
lepers within our own country. 

Leprosy is seen in both sexes, though the male sex is 
rather more often affected. It is rare in children, and is 
never seen in infants ; a strong argument against heredity. 
Its incubation stage is very long, reaching over a period of 
years. It occurs in all countries and climates, but is endemic 
in certain regions. Sporadic cases have been reported, but 
careful investigation would doubtless show that they have 
been exposed to contagion. Vaccination has often been a 
carrier of contagion. 

Pathology. Constantly accumulating evidence points to 
the bacillus leproe as the disease-carrier. This has been 
found in the tubercles, the infiltrations, the lymphatic 
glands, nerves, spleen, liver, walls of the bloodvessels, hair 
follicles, and sebaceous glands. It was discovered by Han- 
sen in 1874, and since then has been studied by many 
pathologists. " They are straight or very slightly curved 
rods, 5 qVo" °f an * ncn * n l en gth, and may have knob-shaped 
expansions at their ends or in their length, due to the pres- 
ence of two to five spores" (Crocker). Inoculation experi- 
ments have often resulted negatively, but some positive ones 
sufficiently prove the claim for the bacilli as propagators of 
the disease. 

Diagnosis. In a fully developed case little difficulty in 
diagnosis can arise. Sometimes lepra will need to be differ- 
entiated from erythema multiforme ; syphilis ; lupus ; and 
morphoea. The presence of anaesthesia in any doubtful case 
will establish the diagnosis of leprosy. Besides this, erythema 
runs a more acute course ; syphilis of the tubercular form 
presents redder tubercles, which ulcerate more readily, are 
grouped, and a history of syphilis is usually attainable ; the 
lupus tubercles are small, of apple-jelly color, soft, do not 
produce thickening of the eyebrows and nodular lobulation 
of the ears, and group themselves in patches in which cica- 
tricial tissue will be found ; morphoea has a lardaceous 
appearance with a violaceous border. 



LEPRA. 289 

Treatment. The best chance for recovery from leprosy 
is removal to a region in which the disease is not endemic. 
This, with attention to hygiene, and a general tonic treat- 
ment, will do a great deal toward a cure. Of internal 
remedies, chaulmoogra oil holds the first rank, with an in- 
itial dose of three minims three times a day, and then gradu- 
ally increased to as high a dose as the patient will stand. 
Nausea, vomiting, and diarrhoea show when this is reached. 
Fox 1 has cured one patient by giving nux vomica or strych- 
nia up to full constitutional effects, and then administering 
chaulmoogra oil continuously. Gurjun oil is also highly 
commended in an emulsion of one part of the oil and three 
parts of lime-water, of which the dose is half an ounce morn- 
ing and night. 

Unna claims to have cured one case with sulpho-ichthyo- 
late of sodium, from six to forty-five grains a day, but others 
who have tried it have not had the same success. Salicy- 
late of soda, thirty grains every four hours till two drachms 
are taken ; salol in full doses ; thymol, forty-five to sixty 
grains a day ; carbolic acid up to fifteen grains a day ; are 
advocated by Lutz, Besnier, and others. The general 
health of the patient should receive attention, and symptoms 
treated as they arise. 

Externally the chaulmoogra or gurjun oil may be rubbed 
in. The ulcers are to be treated upon the usual surgical 
principles. Unna 2 recommends rubbing into all the lesions 
but those on the hands and face, the following : 

R . Chiysarobin, \ 
Ichthyol, j 



Ac salicyLj 2 

Ungt. simpl., 100 



M. 



On the face and hands, he substitutes pyrogallol for the 
chrysarobin. To counteract the bad effects of the drugs, he 
administers thirty drops of dilute hydrochloric acid during 
the day. For women and children he substitutes resorcin 
for the chrysarobin. To old nodes, after protecting the 

1 Post-Graduate, 1885-6, i. 143. 

2 Journ. Cutan. and Gen.-urin. Dis., 1887, v. 381. 

13 



290 DISEASES OF THE SKIN. 

surrounding skin, he applies during five to seven days a 
plaster mull containing twenty to forty parts of salicylic 
acid and forty parts of creasote. Roake 1 advocates excision 
of the tubercles, followed by the application of pure carbolic 
acid. The thermo- or electro- cautery may be used to the 
same end. Segregation is the only preventive measure. 

Prognosis. The prognosis is bad, the disease steadily 
progressing to a fatal termination unless the patient can be 
removed from the endemic region. If he can be removed, 
there is a chance of staying the disease. In some instances 
the disease, even where the patient does not change his 
residence, pauses in its course for a long time ; but it will 
eventually again become active. 

Lepra Alphos. See Psoriasis. 

Lepra Arabum. See Elephantiasis. 

Lepre Vulgaire. See Psoriasis. 

Leprosy. See Lepra. 

Leucasmus. See Leucoderma. 

Leucoderma (Lu'^ko-du^rnV). Synonyms : Vitiligo ; 
Leucasmus ; Leucopathia ; Achroma ; Piebald skin. 

An acquired loss of pigment of the skin characterized by 
the formation of symmetrical white patches with convex 
borders surrounded by an area of hyper-pigmentation. 

Symptoms. This is an acquired anomaly of pigmenta- 
tion, the opposite to chloasma. It is akin to albinismus, 
only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 
scribed round or oval patches so that white areas are formed 
(Fig. 29). At the same time there is an accumulation of pig- 
ment around the areas so that there is a process of apigmen- 
tation and hyper-pigmentation. The size of the patches 
varies greatly. They may be no larger than a ten-cent 
piece, or of immense size. The disease most commonly 
begins upon the neck, face, or backs of the hands, but may 
begin anywhere. It is chronic. It may progress so as 
eventually to involve the whole body ; or it may become 

1 Brit. Med. Journ., 1888, i. 1214. 



LEUCODERMA. 



291 



stationary ; or, in rare cases, the skin may become pig- 
mented again. It is a symmetrical disease in nearly all 



Fig. 29. 




Leucoderma. (After Hyde.) 

cases. The general health is unaffected, and there is no 
change in the sensibility of the patches. In some cases the 



292 DISEASES OF THE SKIN. 

white parts are unusually sensitive to exposure to the sun. 
When the scalp or hairy regions are affected the hair turns 
white. The disease is most evident in the summer on 
account of the increased pigmentation that normally occurs 
in the sound skin at this season. 

Etiology. The cause of the disease is obscure. All we 
can now say is that it is probably a disturbance of innerva- 
tion. It is uncommon for it to occur before the tenth year 
of life, though it may do so. Adults are most frequently 
affected. Both sexes are subject to it. It is more common 
in the warm than in the cold countries, and is particularly 
common in negroes. Exposure to the sun and cold seem to 
be excitants in some cases. It has followed typhoid fever, 
scarlatina, and malarial fever. Wood 1 says that when mulat- 
toes contract syphilis they become several shades lighter all 
over the body. Symptomatically it is seen with morphoea, 
Addison's disease, and alopecia areata. There is also a 
syphilitic leucoderma. I have had one case in a young 
man of eighteen years, who began to smoke tobacco when 
he was six years of age, and had continued to do so. He 
seemed to be in the best of health. 

Diagnosis. There is little difficulty in diagnosis, as there 
is no other disease in which the only symptoms are a loss 
of pigment with surrounding pigmentation. In morphoea 
the patch may be raised, and the skin is changed in texture, 
and there is apt to be a lilac ring about it. In chloasma the 
patch itself is dark with a convex border, while in leuco- 
derma the border of the pigmentation is concave. The 
concave border of the pigmentation will also distinguish 
the disease from chromophytosis, which too is scaly. The 
normal sensation of the patches distinguishes them from 
leprosy, in which the patches are anaesthetic. 

Treatment. Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
faradism may be tried, and nerve tonics given. We must 
content ourselves with making the patches less evident by 
removing the pigment from about them by the means given 

1 Journ. Cutan. and Ven. Dis., 1883, i. 274. 



LEUKOPLAKIA. 293 

under chloasma. Or we can stain the patches so that they 
shall be less white, as by the use of walnut juice. Besnier 
and Doyon believe that they have cured cases in young sub- 
jects by the prolonged use of bromide of potassium inter- 
nally, and saline or bromo-iodide baths externally, with or 
without injections of pilocarpine. 

Leukaethiopes, a name applied to negro albinoes. 

Leucokeratose. See Leucoplakia. 

Leucopathia. See Leucoderma. 

Leucopathia Unguium. This affection of the nails is de- 
scribed by Morison. 1 It consists of white spots in the nail 
which begin in the lunula and gradually approach the free 
end of the nail as it grows forward. Sometimes these take 
the form of stripes or lines. The nail substance is other- 
wise unaltered. The spots are due to air-spaces in the nail 
substance. Why these occur we do not know. Possibly 
there may be a process of fatty degeneration of the nerve 
cells and subsequent absorption of the fat. (Taylor.) Or 
they may be caused by pressing back the nail-fold. They 
are common in the young and coincident with white spots 
in the teeth. (Hutchinson.) 

Leucoplakia (Lu 2 -ko-pla'ki 2 -a 3 ). This is a rare affection 
of the mucous membrane of the tongue, lips, inside of the 
cheeks, and vulva, that has been described under the names of 
psoriasis buccalis, ichthyosis linguae, and tylosis linguae. It 
occurs in the form of ivory-white or bluish- white, glistening, 
smooth, irregularly shaped patches upon the mucous mem- 
branes that maybe a little elevated. They may give rise to 
no discomfort, or they may interfere with chewing and 
speaking. They may be fissured. There is sometimes saliva- 
tion. They are caused by smoking or occur in syphilis, 
psoriasis, lithaemia, stomachic, or intestinal catarrh, diabetes, 
and disturbed nervous influences. Sometimes they arise 
without assignable cause. 

They are obstinate to treatment. It is very essential 
that tobacco be given up if the patient has been in the 

1 Joura. Cutan. and Gen.-urin. Dis., 1887, v. 474. 



294 DISEASES OF THE SKIN. 

habit of using it. It is also necessary to address our 
remedies to the cure or relief of any lithsemic or diges- 
tive disorder ; and to have the teeth put and kept in good 
order. An anti-syphilitic treatment may be tried, but is 
of doubtful value Sometimes they may be removed by 
the daily application of pure lactic acid ; or J- per cent, so- 
lution of bichloride of mercury ; or 10 to 30 per cent, 
solution of salicylic acid ; or 1 per cent, of chromic acid ; or 
2 to 10 per cent, of bichromate of potash ; or by galvano 
or actual cautery. 

The prognosis as to cure is not good. They not infre- 
quently take on a cancerous change. 

Lichen (Li'ke 2 n). This term was formerly applied to all 
papular diseases, and a host of lichens were described. Of 
these, only lichen ruber acuminatus and planus, and lichen 
scrofulosorum, have survived. 

Lichen Circinatus. See Seborrhcea. 

Lichen Moniliformis. See Lichen planus. 

Lichen Pilaris. See Keratosis pilaris. 

Lichen Ruber. Though it is many years since Hebra 
first described this disease, dermatologists are still undecided 
as to many of its essential features, such as whether lichen 
ruber planus is but a form of lichen ruber acuminatus, or a 
disease sui generis ; and as to whether the separate lesion 
of lichen ruber increases peripherally or not. In this 
country the acuminate form of the disease is very rare, only 
twenty-seven cases having been reported to the American 
Dermatological Association for ten years out of a total of 
123,746. Some of these have been questioned as to the 
possibility of their being pityriasis rubra pilaris. While in 
Europe lichen planus is considered as only a form of lichen 
ruber, in this country it is regarded by probably the majority 
of our dermatologists as a separate disease, and will be de- 
scribed as such in this book. On account of the diversity 
in the descriptions of lichen ruber acuminatus, the one here 
given is taken from Hebra and Kaposi (Lehrbuch der 
Hautkranklieiten. 1872). 

Lichen ruber acuminatus. Lichen ruber acuminatus is 



LICHEN" RUBER. 295 

a chronic progressive disease of the skin marked by an 
eruption of small, red, conical papules tipped with a scale. 
These tend to run together and form lines or diffused red, 
scaly, infiltrated patches. 

Symptoms. The disease begins as a discrete eruption of 
milletseed-sized slightly scaly papules, that cause but little 
itching, and therefore are accompanied by but few excoria- 
tions. The papules may be bright or brownish red, conical, 
hard, covered with an adherent, dry, white scale, and im- 
parting, when they are present in a sufficient number, a 
rough feeling to the touch. Or they may be pale red, waxy, 
smooth, rounded, and with a small, angular depression in 
their center. The first outbreak may be scattered about 
the whole trunk and extremities, though somewhat more 
abundant on the flexor surfaces of the latter. Or it may 
be limited for a long time to a single region, such as the 
leg, or genitals. After a time the eruption becomes general 
by the appearance of new papules either at the periphery 
of the first patch, or between the original papules, or irreg- 
ularly over all. The single papules never increase in size 
during their whole course. After a time the papules crowd 
together, and melt into each other, and form continuous, 
red, infiltrated patches of various sizes and shapes, whose 
surfaces are like chagrin leather or covered with scales. 

This is the most common course. Sometimes, however, 
the new papules appear in manifold circular rows about the 
older ones. The older ones sink in, disappear, and leave 
a darkly pigmented depression. The thus formed patches 
are usually on the extremities. 

In a fully developed case the skin is everywhere reddened, 
scaly, and thickened, and the movements of the joints are 
greatly interfered with so that they are held in a semi- 
flexed position. The thickening of the skin is specially 
marked on the palms, soles, fingers, and toes, and here rha- 
gades are prone to form. The nails are thickened, uneven, 
brittle, broken, opaque, yellowish-brown ; or they are only 
represented by thin horny plates. The coarse hair of the 
head, axillae, and pubes is unaffected. (Kaposi, in the third 



296 DISEASES OF THE SKIN. 

edition of his book, says that a defluvium capillorum takes 
place.) 

The subjective symptoms are itching, and a gradual pro- 
gressive interference with nutrition. At first the patient 
may feel quite well, but when the whole body is affected he 
falls into a general marasmus, and at last dies from the 
effects of the disease. 

So far Hebra. Subsequent observers have reported the 
occurrence of a bullous eruption in the course of the 
disease. 

Etiology. The cause of the disease is obscure. It 
affects all ages and conditions, but is most frequent in the 
male sex — about two-thirds of the cases. By many the dis- 
ease is considered to be a neurosis. 

Diagnosis. It is needful to diagnosticate the disease from 
psoriasis, eczema, pityriasis rubra, pityriasis rubra pilaris, 
and lichen ruber planus. From psoriasis it differs, when in 
the early stages, in that its papules do not enlarge into the 
large, characteristic psoriatic papules and patches ; in the 
later stages there is less scaling than in psoriasis universalis, 
and more thickening of the skin ; and the palms and soles 
are far more profoundly diseased. From eczema it differs 
in that its papules neither undergo involution nor change 
into vesicles. Moreover, it does not itch so much, and there 
is never any moisture. From pityriasis rubra it differs in 
the greater thickening of the skin, and in its scaling, which 
is not in the form of thin plates or furfuraceous desquama- 
tion. From pityriasis rubra pilaris it differs in being less 
scaly, in affecting the flexor surfaces by preference, in the 
darker color of the eruption from the first, in being more 
itchy, and in the profound constitutional disturbance. 
From lichen planus it differs in that it does not have its 
favorite locations upon the flexor surface of the wrists and 
insides of the knees, in having conical and not flattened 
papules, in not forming lilac-colored angular patches, and in 
a more frequent general involvement of the skin. 

Treatment. Arsenic, by the mouth or hypodermatically, 
is the drug upon which most reliance is placed for the cure 
of this disease. The drug must be pushed up to its limit of 



LICHEN PLANUS. 297 

toleration and given continuously for a long time, and for 
some weeks after the disappearance of the eruption. The 
hypodermic method is very painful. The external treat- 
ment is by means of tar, if not too irritating ; or we may 
simply address ourselves to the relief of the itching by means 
of carbolic acid, one or two drachms to the pint of olive oil 
or pound of vaseline. Crocker speaks well of thymol or 
naphthol, 10 gr. to 5ij to the ounce of vaseline. Unna's 1 
treatment has proved serviceable in many hands. He 
keeps the patient in bed between woollen blankets, and has 
him rubbed every morning and night with the following : 



Be . Ungt. zinc. oxid. benzoat., % iv ; 500 

Ac. carbolici, 9 i y 5 20 

Hydrarg. bichlor., gr. ij-iv ; 0.5-1 



M. 



For the ointment of oxide of zinc, diachylon ointment 
may be substituted ; or a mixture of oil, lime-water, and 
white bolus may be used instead. Where the corneous layer 
is very thick, two drachms and a half of chalk may be sub- 
stituted for the bolus. 

Prognosis. The course of the disease is essentially 
chronic. Even when a cure is effected, relapses are liable to 
occur. Hebra at first said that all cases were fatal, but the 
use of arsenic and increased experience in the treatment of 
the disease has greatly modified his gloomy prognosis. 

Lichen (ruber) Plan r u 3 s. A chronic disease of the skin 
characterized by the eruption of smooth, waxy, angular, 
umbilicated, red papules, that tend to form scaly, lilac- 
colored, elevated and infiltrated patches specially upon the 
flexor surfaces of the wrists, and the inside of the knees. 

While the testimony from skilled observers is overwhelming 
that lichen planus papules may occur with lichen acumina- 
tum, and while some cases of lichen acuminatus have de- 
veloped after and together with lichen planus, still we see so 
many cases of the latter occurring by itself, that it merits a 
special description. In this country and in England lichen 
planus is far more frequent than is lichen acuminatus. 

1 Monatshefte f. prakt. Dermat., 1882, i. 5. 
13* 



298 DISEASES OF THE SKIN. 

While the latter occurred but 27 times in 123,746 cases, the 
former occurred 154 times in the same number of cases, 
according to the statistics of the American Dermatological 
Association. 

Symptoms. The disease begins as an eruption of small, 
purplish- or crimson-red, angular, flat, slightly raised papules, 
varying in size from ^ to -J- of an inch in diameter. 
Their surface is smooth and shiny, u waxy-looking," and 
they have a small depression in their centre. The papules 
may remain discrete, and be disseminated over a larger or 
smaller area ; or they may arrange themselves in rows, or 
aggregate themselves into patches, the single papules dis- 
appearing. The single papules are not scaly, the patches 
are slightly so. The patches may be small, and if so there is 
apt to be a well-marked depression in their centre, and their 
shape is round or oval. The larger patches have no definite 
shape nor depression, but are well defined, and elevated. 
The color of the patches is characteristic, and may be de- 
fined as lilac. If the color is once seen it will be an impor- 
tant aid in the diagnosis of future cases. Both the papules 
and patches on disappearing leave behind pigmented spots, 
which, after a time, fade away. It is still a moot point as 
to whether the individual papule enlarges peripherally or not. 
Like those of psoriasis, the papules of lichen planus may 
appear upon scratched surfaces. 

The disease is most often met with upon the anterior 
surface of the wrists and forearms, and upon the inside 
of the knees, the former being the favorite location. But 
it may occur anywhere, other favorite locations being the 
flanks, lower part of the abdomen, and the calves, and it 
may involve a large part of the body, though it rarely be- 
comes general. When the papules disappear after lasting 
many weeks they leave behind them pigmented depres- 
sions, which later may become white. The mucous mem- 
branes of the lips and mouth are affected but rarely and 
the disease then appears as white spots difficult if not 
impossible of diagnosis, without the occurrence of the typical 
eruption on the integument. As a rule there is more or 
less symmetry shown in the disposition of the efflorescences ; 



LICHEN PLANUS. 



299 



and pruritus, which sometimes is marked. The general 
health is often unaffected, but, on the other hand, many of 
the subjects of the disease are not in perfect condition when 



Fig. 30. 




Lichen ruber moniliformis. (After Taylor.) 

the disease begins, and not a few others become greatly 
broken down on account of the loss of sleep and continual 
discomfort caused by the pruritus. The course of the dis- 
ease is chronic, and new outbreaks are liable to occur. True 
relapses are not liable to occur when the disease is once 
cured. 



300 DISEASES OF THE SKIN". 

Kaposi 1 has described a unique form of this dis- 
ease under the name of lichen ruber moniliformis, in 
which the typical lesions became transformed into keloidal 
nodes arranged in lines (Fig. 30). The nodes were in some 
places as large as cherries with their bases confluent and their 
upper parts separated by furrows. The cases of this sort 
that I have seen in this country occurred in what were 
rather lichen ruber acuminatus or pityriasis rubra pilaris. 
Unna 2 describes what he names lichen obtusus, a form of 
papule midway between the acuminate and the plane. They 
are large and waxy, discrete papules, often bluish -white, not 
scaly, and but slightly itchy. A lichen verrucosus and a 
lichen hypertrophicus have also been described. Pemphi- 
goid eruptions occasionally occur as part of the disease. 
Crocker says that there is an infantile form of the disease 
in which the papules come out acutely in groups, acuminate 
at first, but soon becoming flat, angular, and red changing to 
purple. It is itchy, and tends to rapid recovery in a few 
weeks under soothing applications. 

Etiology. We know no more about the causes of lichen 
planus than we do about those of lichen acuminatus. A 
neurotic element is marked in many of the cases, and cases 
have been reported in which the papules were distributed 
along the course of a nerve. 3 Nervous exhaustion, rheu- 
matic sweating, and checking perspiration are given as 
causes. Its subjects are mostly adults. It is more frequent 
in men than in women. 

Pathology. u In the plane form the process appears to 
be inflammatory, beginning usually round a sweat duct in 
the upper part of the corium, with subsequent thickening 
of the rete and enlargement of the papillas by down growth 
of the inter-papillary processes." (Crocker.) The fact that 
the mucous membranes are affected is brought forward as an 
objection to the view that the process begins in the sweat 
duct. Robinson thinks that the process begins as an in- 

1 Vierteljahr. f. Dermat. u. Syph., 1886, xiii. 571. 

2 St. Petersburg, med. Wochenschrift, 1884, i. 447. 

3 Mackenzie : Brit. Med. Journ., 1884, ii. 1077. 



LICHEN POLYMORPHE CHRONIQUE. 301 

flammation of the papillae and upper part of the coriurn. 
The form of the papule is determined by the shape of the 
so-called "skin fields." 

Diagnosis. An eruption of flat, shiny, angular, umbili- 
cated papules of a lilac color situated on the anterior sur- 
faces of the wrists can be nothing but lichen planus. These 
same characteristics are diagnostic anywhere on the body, 
and sufficient to diagnosticate the disease from eczema and 
psoriasis. Moreover, eczema will show a tendency to moist- 
ure, or the papules will undergo change ; and psoriasis 
will be almost sure to have characteristic patches upon the 
elbows and knees, covered with more abundant white and 
ofttimes thick scales. Syphilis sometimes bears a strono- 
resemblance to lichen planus, but itching is less marked, its 
eruption is more polymorphous, and its color is more that 
of raw ham. 

Treatment. In the treatment of lichen planus, arsenic, 
nerve tonics, and attention to the general health as well as 
to the hygiene both of the body and mind, are our most 
reliable agents. Alkaline diuretics sometimes do well, as 
the acetate of potash. Locally, stimulants such as tar, 
pyrogallol, and chrysarobin will prove serviceable. Unna's 
ointment, as given under lichen ruber acuminatus, is proba- 
bly our most reliable application. In acute cases alkaline 
lotions will allay irritation. Thymol and naphthol may be 
tried as in lichen acuminatus. In chronic cases Hardaway 
recommends : 



u 


Saponis olivse prep., 




3 iv ; 


100 




Olei rusci, \ 
Glycerinae, J 


aa 


3J; 


25 




01. rosmarini, 




3jss ; 


4 




Alcoholis, 


ad 


I vii J ; 


200 



M. 

well rubbed in with a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. Some 
cases in which the skin is very irritable are best treated by 
means of prolonged simple or medicated emollient baths. 

Prognosis. The prognosis is generally favorable, though 
the disease is often very obstinate. ■ 

Lichen Polymorphe Chronique. See Prurigo. 



302 DISEASES OF THE SKIN. 

Lichen Scrofulosorum (L. SknyT-ni-os-orVm) or Scrofu- 
losus. A disease of the skin occurring in strumous subjects, 
consisting in an eruption of small pale papules that tend to 
group in round or halfmoon-shaped figures upon the ab- 
domen, sides of the chest, and flanks. 

Symptoms. It occurs in the form of pinpoint to pinhead- 
sized, grouped, conical papules, which may be of the color of 
the skin, or pale red, or fawn-colored. These papules occur 
around the hair follicles and form small round groups, or 
circles, or segments of circles, upon the abdomen, sides of 
the chest, flanks, and neck in adults ; and upon the extremi- 
ties in children. They are somewhat scaly, but give rise to 
no inconvenience, so that they are often overlooked. In 
some cases the papules are so numerous that the groups 
lose their distinctive shape, and large surfaces are covered, 
giving the skin then a dirty-brown color. Many dissemi- 
nated and discrete papules are scattered over the body out- 
side of the patches. Acne pustules may form ; and a brown 
pigmentation of the face has been observed in some cases. 
The papules finally undergo absorption, desquamate, and 
leave transitory yellowish pigmentation. The disease runs 
a chronic, slow course. Eczema may complicate matters. 
Keratosis pilaris is frequently well-marked upon the limbs. 

Etiology. The great majority of the subjects of this 
disease present evidences of scrofula. A few are robust. 
Some are phthisical, especially the children. The disease 
is most common in childhood, and is excessively uncommon 
after the twenty-fifth year of life. 

Diagnosis. The disease must be diagnosticated from pap- 
ular eczema, the papular syphilide, lichen ruber, a punctate 
psoriasis, and keratosis pilaris. Eczema differs from it in 
greater itching, in the brightness and rapid development of 
the papules, and in its tendency to vesiculation or moisture. 
The papular syphilide is of darker red color, much larger, 
and more polymorphous ; the patient's age is greater, and 
the history and course of the eruption will soon decide the 
diagnosis. Lichen ruber acuminatum has darker papules, 
which do not group in circles and segments of circles ; they 
itch, and tend to involve the whole surface. The patients 



LUPUS ERYTHEMATOSUS. 303 

are more often adults, and there is a profound constitutional 
disturbance. Psoriasis itches, is abundantly scaly, and its 
papules soon enlarge and form characteristic patches. 
Keratosis pilaris affects the extensor surfaces of the limbs 
by preference, each papule is plainly about a hair, and the 
papules do not group. A curled up hair will often be found 
in the centre of the papule. 

Treatment. The persistent use of cod-liver oil both 
internally and externally will cure the disease. The syrup 
of the iodide of iron may be given with the oil. Good 
hygiene and food are valuable adjuncts. For the cod-liver 
oil, which is disagreeable for external use, other oils, such as 
cocoa butter, may be used ; or vaseline with or without oil 
of cade. Crocker recommends the addition of liq. plumb, 
subacetatis, nixv, or thymol, 5 grains to the ounce of 
vaseline. 

Lichen Simplex. See Papular eczema. 

Lichen Syphiliticus. See Papular syphilide. 

Lichen Tropicus. See Miliaria. 

Lichen Urticatus. See Urticaria. 

Lineae Albicantes. See Atrophoderma. 

Linsenflecken. See Lentigo. 

Liodermia Essentialis. See Angioma pigmentosum et 
atrophicum. 

Lipoma is a fatty tumor. 

Lombardian Leprosy. See Pellagra. 

Lousiness. See Pediculosis. 

Lues. See Syphilis. 

Lupoid Acne. See Acne frontalis, and Lupus miliaris. 

Lupus Erythematosus (Lu'pus Er 2 -i 2 -the 2 m-a 2 t-os / u 3 s). 
Synonyms : Seborrhoea congestiva ; Lupus superficialis ; 
Lupus sebaceus ; Lupus erythematodes ; Scrofulide erythe- 
mateuse, or Erytheme centrifuge (Fr.) ; Dermatitis glandula- 
ris erythematosa (Morison) ; Ulerythema (L^nna). 

This is a chronic disease of the skin, occurring in variously 
sized, slightly elevated, scaly, red patches which show a 
strong tendency to the production of atrophic scars. 



304 DISEASES OF THE SKIN. 

Symptoms. There are two varieties commonly described, 
namely, the circumscribed or discoid, and the diffuse, or dis- 
seminated, or aggregated. To these some of the English 
writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 
met with. It occurs generally on the face, specially upon 
the sides of the nose and the cheeks, the scalp, and the 
ears ; more rarely upon the hands and feet ; and still more 
rarely on other parts of the body. It begins by the 
appearance of several isolated or grouped red spots slightly 
elevated, of pinhead to split-pea size, with a thin ad- 
herent scale upon them. Some of these spots may be 
depressed in the centre. When the scale is removed there 
will be found upon its under side a delicate projection 
formed by a plug of sebaceous matter that dipped down into 
the mouth of the sebaceous gland. The mouth of the 
gland will be found patulous. These spots increase in size 
to form disc-shaped figures of varying size ; neighboring 
ones will coalesce, and thus patches will be formed, also 
covered with the fine grayish or white adherent scales. 
Now when the scale is raised a number of the characteristic 
prolongations will be found on its lower side. The margins 
of the patches are slightly raised but the middle parts 
undergo involution, are lower than the margins, and after a 
time are apt to assume a cicatricial appearance, the skin 
being atrophied. 

The scar tissue thus formed is thin, delicate, and white, 
never puckered or deforming. The color of the patches is 
red, but of a peculiar hue that is characteristic, and perhaps 
can be best defined as violaceous. There is never any 
moisture connected with the disease. Burning or itching 
may or may not be present. The patches are of indefinite 
duration — months or years. At times they disappear of 
themselves, and do not leave scars, but the rule is that scars 
are left. The extent of the disease varies greatly, as well as 
the shape of the patches. The greater part of the face may 
be involved, or there may be only a single patch. Usually 
the eruption is symmetrical. A characteristic location for 
the disease is upon the back and sides of the nose and the 



LUPUS ERYTHEMATOSUS. 305 

contiguous parts of the cheeks, forming what has been fanci- 
fully called a butterfly, the ridge of the nose representing 
the back of the animal, and the cheeks its wings. Some- 
times gvrate figures are formed. The mucous membranes 
and the vermilion border of the lips may be affected. 
Occurring upon the scalp it leads to permanent loss of hair, 
and the same may be said of it as it occurs on other hairy 
parts. The disease may become stationary after a time. 
Relapses are liable to occur. The general health is un- 
affected. 

The diffuse or disseminate form is a more acute process, 
and exceedingly rare in this country. In it the patches 
may appear suddenly, or slowly develop. They are from 
pinhead to finger-nail size, slightly elevated, reddish-brown, 
hyperceruic and hard ; they are pale under pressure, and are 
attended with heat and burning. In this stage thev resemble 
an urticaria, or the papular stage of eczema. There may be 
twenty to a hundred or more of them, crowded together upon 
the face and scattered over the bodv. Manv of them may 
disappear in a few days without leaving any trace, while 
others will remain and become characteristic lupus erythe- 
matosus patches with depressed cicatrices. The individual 
lesions do not increase in size, and the patches are formed 
by aggregations of single lesions. The eruption may be 
accompanied by a high degree of inflammation, exudation, 
and crusting, or even by bullae. There may be deep, painful 
subcutaneous tumors in the joints and glands at first, over 
which characteristic patches will form. In some acute cases 
the development of the patches is accompanied by fever, 
osteocopic pains, and nocturnal headache. Or there may 
be a persistent inflammation of the face, erysipelas perstans, 
which may lead through a typhoid state to death. There 
mav be also swelling of the parotid glands, and of various 
lymphatic glands. In some cases the disease bears a close 
resemblance to chilblain. 

The telangiectic form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection 
shows to be due to dilated vessels, and is commonly located 
symmetrically upon both cheeks. Upon pinching up the 



306 DISEASES OF THE SKIN. 

skin it will be found to be markedly thickened. Some few 
comedones may be present. There is no desquamation. 

Etiology. About two-thirds of the cases occur in women. 
It seldom occurs before puberty, though Kaposi has seen a 
case in a child of three years. Beyond these facts we know 
but little about its etiology. The French regard it as a scro- 
fulous affection. Nothing suggesting its relation to a tuber- 
culous process has ever been found in the skin. It is true 
that some few cases have reacted to tuberculin injections, but 
that is no proof of its tubercular origin. On account of not 
a few patients having other symptoms of a general tubercu- 
losis, Besnier regards lupus erythematosus as allied to lupus 
vulgaris, as a species of tuberculosis of the skin. Crocker 
suggests a feeble circulation, and prolonged exposure to 
great cold or heat as possible causes. It would also seem 
that those who are subjects of seborrhcea are predisposed to 
the disease. 

Pathology. In spite of much careful study it is still 
undetermined whether the disease is inflammatory or not 
In the majority of cases the disease begins about the seba- 
ceous glands and hair follicles. It may also begin in the 
sweat glands, or in any part of the skin ; or in the deeper 
layers of the skin around the vessels of the sweat or seba- 
ceous glands. The cicatricial scarring is the result of 
atrophic processes. 

Diagnosis. The disease must be differentiated from 
lupus vulgaris, eczema, rosacea, psoriasis, and syphilis. A 
typical case occurring upon the face in the form of red 
patches, with fine cicatrices in the centre, and covered with 
a delicate white or grayish adherent scale from the under- 
side of which are a number of projections, offers no difficulty 
in diagnosis. Lupus vulgaris differs from lupus erythema- 
tosus in occurring before puberty, in showing no disposition 
to symmetry, in the presence of apple-jelly tubercles, in 
being a deeper-seated disease, and in leading to far more 
disfiguring cicatrices. Eczema never leaves scars, is prone 
to exudation, itches, its scales do not show prolongations 
from the underside, and its patches undergo more rapid 
and varied changes. Psoriasis will be pretty sure to show 



LUPUS EKYTHEMATOSUS. 307 

characteristic patches covered with thick scales, and never 
causes scarring or leads to permanent loss of hair. Rosacea 
is largely composed of dilated bloodvessels, occupies the 
middle third of the face, often presents superficial pustules, 
does not leave scars, and is subject to frequent exacerba- 
tions. In syphilis a history of other lesions will be attain- 
able, there will be more evident infiltration, and the course 
of the lesions will be more rapid. The disseminate form of 
the disease would be very difficult of diagnosis at first, but 
as soon as characteristic patches form, the difficulty would 
be removed. 

When lupus erythematosus occurs upon the scalp it 
causes a bald spot that may be mistaken for alopecia areata, 
but differs from it in its irregular shape, in the signs of 
inflammation in it, and in the cicatricial condition of the 
scalp it leaves. A microscopical examination of the hairs 
from about a patch will decide as between lupus erythema- 
tosus wndifavus or ringworm. 

Treatment. Little beyond the care of the general con- 
dition of the patient upon general principles can be done 
for lupus erythematosus in the way of internal medication. 
McCall Anderson advocates the use of iodide of starch, 
made by triturating twenty-four grains of iodine with a little 
water, and gradually adding one ounce of starch, rubbing 
them well together until a deep-blue color of the mass is 
struck. Of this a heaped teaspoonful, increased gradually, 
may be given three times a day in water or gruel. Iodide 
of potassium is also commended, as is phosphorus. 

Our main reliance is upon external treatment. Some- 
times in the early stages alkaline washes, such as lotions of 
zinc or lead, may be used. Or one composed of — 

R • Zinci sulpliatis, ) - - _ • 

ti, ) " 3i; 



Potassii sulphureti 

Alcohol., 3 iij ; 10 

Aqua? rosae, ad % iv ; 100 



M. 



as in acne and rosacea. Green soap or prepared olive soap, 
or its tincture may be used in more chronic cases. This is 
often serviceable for the disease, as it attacks the eyelids. 
The affected parts are to be well rubbed with it, using a piece 



308 



DISEASES OF THE SKIN. 



of flannel. The process is to be repeated every few days. 
If the reaction is too great, a little oil or a glycerin lotion 
may be applied. Crocker advocates the addition of one 
or two drachms of the oil of cade to the ounce of the 
tincture of the soap. Carbolic acid, pure, applied to the 
patches, often acts admirably. It turns them white at first. 
The application is to be repeated as soon as the crust 
falls. Fowler's solution applied externally is sometimes 
efficacious, but painful. Pyrogallic acid, 10 per cent, in 
ointment, sometimes does well ; as also chloracetic acid ; 
oil of cade ; solution of naphthol, 1 per cent. ; resorcin 3 
to 10 per cent, strength in solution or ointment ; tincture of 
iodine or iodide of glycerin ; caustic potash, one part to six 
or twelve of water. Hydronaphthol plaster and resorcin plas- 
ters of 10 to 20 per cent, strength, and mercurial plaster, 
are often excellent when persisted in. Sulphur or ichthyol 
in ointment or paste do well in some cases. All cases should 
be carefully watched that the reaction from our remedies 
does not go too far. If these superficial caustics do not 
cure, resort may be had to linear scarifications, making a 
series of cross-hatchings, taking care not to go very deep 
(Fig. 31). The bleeding is to be checked by pressure and 



Fig. 31. 




Scarify ing-knife. 

the application of carbolic acid, two drachms to the ounce. 
Limited surfaces must be taken at a time. Electrolysis by 
means of multiple punctures will sometimes give brilliant 
results. Sometimes running the needle across the patch, 
making a number of parallel insertions, will have a good 
effect. Ecrasion with the curette, the galvano or Paquelin 
cautery, and strong escharotics, such as the acid nitrate of 
mercury, may have to be used in very obstinate cases, but 
not till all other means are exhausted, as they are apt to 
leave deep scars. 

Prognosis. The prognosis should be guarded, as the 



LUPUS VULGARIS. 309 

disease is a most obstinate one and prone to relapses. A 
cure may, however, be effected by patient perseverance. It 
is wise always to tell our patients that scars are liable to be 
left, not only by the treatment employed, but by the disease 
itself. The discoid form has little effect upon the health of 
the patient, but the disseminated variety not infrequently 
ends fatally. 

Lupus Exedens. See Lupus vulgaris. 

Lupus Exfoliativus. See Lupus vulgaris. 

Lupus Exulcerans. See Lupus vulgaris. 

Lupus Hypertrophicus. See Lupus vulgaris. 

Lupus Sclereux. See Tuberculosis verrucosa cutis. 

Lupus Sebaceus. See Lupus erythematosus. 

Lupus Superficialis. See Lupus erythematosus. 

Lupus Tuberculosus. See Lupus vulgaris. 

Lupus Verrucosus. See Lupus vulgaris. 

Lupus Vorax. See Lupus vulgaris. 

Lupus Vulgaris (L. Vu 3 l-ga-ri 2 s). Synonyms : Besides 
those given above, which merely describe certain stages or 
forms of the disease and are quite unnecessary to be re- 
membered, we have : Noli me tangere ; Herpes esthiomenos ; 
(Fr.) Dartre rongeante, Scrofulide tuberculeuse, Esthio- 
mene ; (Ger.) Fressende Flechte. 

This is a chronic neoplastic disease of the skin probably 
due to its invasion by the tubercle bacillus, and character- 
ized by one or more brownish-red papules, tubercles, or in- 
filtrated patches, that tend either to absorption or ulceration, 
and always leave scars. 

Symptoms. Lupus vulgaris usually begins in childhood 
and upon the face ; the cheek and nose being the parts most 
usually affected. The initial lesion is a dark-red or brown 
pinpoint to pinhead- sized papule, which may be on a 
level with the skin, depressed below, or raised above it. 
There may be but a single lesion, but more usually there 
are a few of them either grouped or scattered. After a 
time slightly scaly patches will form by the coalescence of 
the lesions which have enlarged, into brownish-red, semi- 



310 DISEASES OF THE SKIN. 

translucent, smooth, shiny tubercles, or by the development 
of new lesions between the old ones. The size of the patches 
varies greatly, but they are always elevated above the sur- 
face of the skin, of a dark-red color, and studded with the 
little brownish-red papules, or so-called tubercles. The 
appearance of these tubercles has been likened by Hutchin- 
son to that of apple-jelly. There may be but one patch, or 
the whole face may be more or less covered with a number 
of them. Symmetry is not a feature of the disease, often 
only one side of the face being affected. Sometimes two or 
more patches will coalesce at their borders, their centres will 
fade out, or rather become atrophic, and we will have a 
gyrate patch creeping over the skin with a well-marked, 
elevated, red border. The centre of all the patches is lower 
than the border, and eventually is atrophic. The course of 
the disease is slow and chronic, and the fate of the patches 
varies greatly. For months or years they may remain 
absolutely quiet, and then show signs of activity by new 
lesions appearing about the edges of the patches or in the 
scar tissue. The patches may entirely disappear, leaving 
a fine, smooth cicatrix ; this is rare without treatment. 
Or they may break down and form ulcers which are irregu- 
larly rounded in shape, shallow, with easily bleeding floors, 
and a moderate amount of purulent secretion that dries into 
a crust. This is the so-called lupus exulcerans and is not 
very frequent in this country according to my experience. 
Sometimes upon this ulcerated surface papillary or warty 
growths will spring up, the so-called lupus papillomatosus 
or verrucosus. Sometimes the infiltration of the patch is 
unusually great, and then we have lupus hypertrophicus. 
Most commonly we have a non-ulcerated, exceedingly chronic 
infiltrated patch with areas of cicatricial tissue scattered 
through it. When the disease attacks the end of the nose 
it will cause it to shrink up and convert it into cicatricial 
tissue. When the ear is diseased it also shrinks up so as to 
be half the size it was originally. These changes are 
due either to ulceration or to the gradual absorption of the 
lupus tubercles that they all undergo. 

While the face is the site of predilection of lupus, it may 



LUPUS VULGARIS. 311 

also occur upon any part of the skin of the body, as well 
as upon the mucous membranes. In this latter situation it 
is most often secondary to the disease elsewhere, still it is 
often primary. Thus Bender 1 found that 30^ per cent, of 
all his lupus cases began in the nasal mucous membrane. 
Pontoppidan also found the origin of the disease to be the 
nasal mucous membrane in many cases. In the nose it 
frequently leads to perforation of the septum and sometimes 
great deformity of the nose, but it does not attack the 
bones. All other mucous membranes may be attacked ; the 
rectum and vagina being least often affected. The con- 
junct va3 may be involved primarily or secondarily. Epi- 
thelial cancer has developed in very rare instances upon the 
lupoid tissue itself, more commonly upon the scar tissue left 
by the lupus. Whenever it develops as a sequela of lupus 
its course is much more rapid and its prognosis far more 
grave than is usually the case. Erysipelas is a not infre- 
quent complication of lupus, and is sometimes curative in 
its action. Lupus of the extremities is often followed by 
permanent deformities and disabilities, and sometimes by 
tubercular lymphangitis. Implication of the lymphatic 
glands is exceptional in lupus, and then only in advanced 
cases. 

Etiology. Lupus has long been regarded as a manifes- 
tation of scrofula. It is now pretty well demonstrated that 
it is a tubercular disease. It should be placed under the 
division of tuberculosis cutis, but usage makes it advisable to 
consider it by itself. Many patients with lupus are plainly 
strumous ; many, 55 j 9 ^- per cent, of SachV cases, are either 
tuberculous themselves or have a decided history of the 
occurrence of phthisis in their family. The phthisical his- 
tory is far less pronounced in this country than it is in 
Europe. It is no uncommon thing for several members of 
the same family to have lupus. It is probable that we 
could find a close connection between lupus and infection 
with the tuberculous virus in all cases, were it practicable 
to do so. Another evidence of its tubercular origin is 

1 Yierteljahr. f. Derm, mid Syph., 1888, xv. 891. 

2 Ibid., 1888, xiii. 241. 



312 DISEASES OF THE SKIN. 

found in the nearly uniform reaction of lupus to tuberculin. 
Beyond this it is not necessary to search for a cause. It 
is much more frequent in females than in males, about 62 
per cent, being in females according to Block's and Sach's 
statistics. It begins in more than half the cases before the 
fifteenth year. It may begin as early as the second year. 
It is almost always a disease of youth. 

Pathology. The pathology of lupus has been studied 
by many competent investigators. As their results do not 
altogether agree, this is no place to discuss them. " It is a 
neoplasm of the granuloma class, and consists of a small 
cell infiltration which begins in the deep part of the corium, 
and from thence gradually invades all the other skin struc- 
tures," says Crocker. The tubercle bacillus is found in the 
tissues, though but sparsely. Inoculations have not always 
been successful, but in a goodly number of cases the inocu- 
lations have been followed by general tuberculosis, so as to 
warrant our belief in the tubercular nature of the disease. 
It- has been suggested that as the bacilli are present in but 
a small number, the irritation of the tissues is due to the 
ieucomaines produced by them. 

Diagnosis. Lupus is most commonly confounded with a 
tubercular or gummous syphilide. It may have to be dif- 
ferentiated sometimes from a scrofuloderm originating in a 
caseous gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosticated by the pres- 
ence of the characteristic apple-jelly tubercles ; by its slow 
course ; by its history ; by the absence of all other signs of 
syphilis ; by its little tendency to ulceration ; by the super- 
ficial character of its ulcers and their slight crusting ; and 
by its sparing the bones. If there is still any doubt, appeal 
may be made to the effect of treatment by means of the 
iodide of potassium and mercury, which will have no effect 
upon the lupus. As the scrofuloderm is another manifesta- 
tion of the tubercular diathesis and amenable to the same 
treatment as that of lupus, its differentiation is not so im- 
portant. It, however, will begin about a caseous and broken- 
down lymphatic gland, will probably have sinuses, and no % 
characteristic tubercles. An epithelioma begins usually 



LUPUS VULGARIS* 313 

after the thirty-fifth year ; has no tubercles ; and forms a 
deep ulcer with raised, hard, waxy edges crossed with 
dilated bloodvessels. The diagnosis from lupus erythema- 
tosus is given in the preceding section. Leprosy presents 
large tubercles which are anaesthetic, and this at once 
decides in its favor. 

Treatment. As lupus is a tubercular disease, and some- 
times is followed by tuberculosis of the lungs, care must be 
given to the general health of the patient, and he must be 
placed in the best possible hygienic surroundings. His diet 
should be nutritious, and cod-liver oil, iodine, and iron 
should be given. But external treatment is of the greatest 
importance, and the disease must be gotten rid of root and 
branch. If a single diseased cell remains, the disease is 
sure to return. To effect its destruction surgical procedures 
had best be resorted to. The whole patch or patches may 
be scraped out with the dermal curette, and this followed by 
a 25 or 30 per cent, pyrogallol ointment for a week or ten 
days, and that in turn by the mercurial plaster for another 
equal term. The pyrogallol will cause free suppuration and 
destroy the cells left behind by the curette. A second or 
third course may be necessary. Piffard prefers to touch the 
base left after curetting with the galvano-cautery at a red 
heat. The wound is then to be packed with absorbent 
cotton. After about ten to fourteen days the crust and 
cotton will fall off and leave a soft, smooth, pliable cicatrix. 
Multiple scarifications have proved of great use. They may 
be made with many-bladed instruments constructed for the 
purpose, or with a scalpel, or a knife shaped like a butcher's 

Fig. 32. 



Scarify ing-kuife. 

cleaver (Fig. 32). They must go deep enough to pene- 
trate all the softened tissue but not to w T ound the sound 
parts. The resistance offered by the healthy tissues will 

14 



314 DISEASES OF THE SKIN. 

be sufficient guide for this. The scarifications should be so 
made as to divide the tissues into little squares, thus : 




They may be repeated in five or six days, and need no after- 
treatment. This is Vidal's method. The individual tuber- 
cles may be bored out with Morris's double- screw instru- 
ment, or with dental burrs and hooks as proposed by Dr. 
George H. Fox. Pure carbolic acid may be introduced 
into the little holes so left to further insure the destruction of 
the disease. The galvano or Paquelin cautery may be 
employed to destroy the disease. This will require the 
administration of an anaesthetic, while the former procedures 
do not require it, or at most anything more than local 
anaesthesia by means of cocaine. Multiple punctures by 
means of the galvano- or thermo-cautery at sombre red heat 
at 1 mm. distance for small patches, and linear scarifications 
with cautery knife for large ones, followed by emplast. 
vigo, and repeated once a week, is Besnier's method. Elec- 
trolysis in multiple punctures or by passing the needle 
through the patch, or by means of a flat metallic button, is 
a useful mode of treatment. The current must be 3 to 5 
milliamperes, and it must be continued for five minutes when 
the button is used. Auspitz recommends puncturing the 
patches in many places with a steel point dipped in carbolic 
acid. Small patches may be excised. 

These surgical procedures have largely superseded the 
use of caustics, though the latter are valuable and may be 
used where the patient fears an operation. Arsenic may be 
employed in the form of a paste such as Hebra's modifica- 
tion of Cosme's Paste : 

R . Ac. arsenios., gr. x ; 2 

Hydrarg. sulphureti rubri, 3 j ; 12 50 

Ungt. aq. rosse, ^j ; 100 M. 

which is to be spread on lint or linen, applied evenly, and 
bound down firmly. It is to be left on for twenty-four 
hours, then removed and reapplied till ulceration is set up. 



LYMPHANGIECTASIS. 315 

It is painful. Vienna paste, of equal parts of cautic potash 
and unslacked lime; or a chloride of zinc paste may be 
used, such as 1 part of zinc to 3 parts of starch. Both are 
painful. Many think highly of boring into the patch with 
the solid nitrate of silver stick. Salicylic acid, 10 to 20 per 
cent, in plaster or plaster muslin changed once or twice a 
day, is good. It is well to combine creasote with the 
salicylic acid in equal parts to allay the pain caused by the 
acid. The local application of bichloride of mercury in 
solution (gr. j to oj) to ulcerated forms, and in ointment 
to non-ulcerated forms, is commended by White and others. 
Unna 1 recommends painting with pure carbolic acid 
for from two to four days. He has also had good 
results with a salve muslin containing 1 per cent, of 
bichloride of mercury, 20 per cent, of carbolic acid, and 36 
per cent, of oxide of zinc. Tuberculin has not proved as 
valuable as it promised. Only very few cases have been 
reported as cured. The inconvenience, depression, and 
sometimes fatal results from the remedy render it an unfit 
one for use. 

Prognosis. The prognosis should always be guarded. 
Relapses after any plan are too often seen. A scar must 
result both from the disease and its treatment. The possi- 
bility of the development of a general tuberculosis must also 
be borne in mind, although most patients preserve through- 
out the course of the disease a robust state of health. 

Lupus Miliaris or Lupoid or Adenoid Acne is a rare 
disease of the skin that occurs upon the cheeks in the 
form of discrete, pinhead-sized, deep-red, slightly raised 
papules, which do not tend to suppurate. Sometimes the 
papules will disappear, leaving a pit behind. The papules 
must be treated by very much the same remedies as are 
useful in lupus, such as by salicylic acid plaster, or acid 

nitrate of mercurv. 

«/ 

Lymphadenoma. See Mycosis fungoide. 
Lymphangiectasia (Li 2 mf-a 2 n-ji 2 -e 2 k r ta 3 -si 2 s). Varices of 
the dermal lymphatics may be superficial, or deep ; and affect 

1 Monatshefte f. prakt. Derm., 1891, xii. 341. 



316 . DISEASES OF THE SKIN". 

the trunk, the meshes, or the lacunse, though most com- 
monly all parts of the vessels are diseased. When they are 
superficial they form ampullary swellings at the surface of 
the skin, which may be isolated or agglomerated. In size 
they vary from the size of a millet-seed to that of a pea, or 
larger. In color they vary with that of the skin. They 
break more or less easily and discharge the lymphatic fluid. 
If deep they can be more readily felt than seen, or form 
upon the surface of the skin isolated or associated raised 
cords which run a more or less tortuous course. After a 
time these also break and discharge lymph. 

Hallopeau and Goupil 1 describe under this title a disease 
that they believe to be of tubercular origin, and that appears 
about a bony prominence of the extremities as a diffuse 
tumefaction, or a cushion-like elevation resembling varicose 
vein tumors. They eventually open and discharge pure 
lymph, or lymph mixed with pus. Fresh tumors arise in 
the course of the lymphatics in an ascending series : also 
gummy nodes. The affected limb is swollen, indurated, and 
of more or less sombre red. The prognosis is grave, and 
the proper treatment undetermined. 

Lymphangioma (Li 2 mf-a 2 n-ji 2 -o'ma 3 ), also called Lymph- 
angiectasis, Lymphangiectodes, Lupus Lymphaticus, and 
Lymphorrhagica Pachydermia, is an exceedingly rare 
disease. It consists, according to Crocker, in a number of 
minute, deep-seated vesicles, closely crowded together in 
irregularly outlined groups of from one-third to one-quarter 
of an inch in size. These groups are arranged irregularly 
with healthy skin between them, or a few scattered vesicles 
in the otherwise healthy skin. They are usually confined 
to a single small area. The vesicles are deep-seated with 
thick walls, some of them almost warty-looking. They are 
pinpoint to hempseed-size, colorless or straw-colored, or 
pinkish, and contain a clear fluid. Some have vascular 
strise or tufts over them, others red clots, others contain ex- 
travasated blood. 

They run a chronic, non-inflammatory course, spreading 

1 Ann. Derm, et Syph., 1890, i. 957. 



MELASMA. 317 

slowly at the periphery, and tending to relapse if removed. 
Most of the few cases have occurred in males and began in 
early childhood. 

The disease is of lymphatic origin, and the main feature 
is dilated lymphatic vessels. 

The treatment consists in destruction by caustics, excision, 
or electrolysis, but relapses are liable to occur. 

A number of other rare affections of the lymphatics have 
been named lymphangioma. The present state of our 
knowledge in regard to them is by no means exact. One 
variety is named by Kaposi 

Lymphangioma Tuberosum Multiplex. This is a still 
more rare disease than lymphangioma, and consisted, in 
Kaposi's case, in the appearance all over the trunk and neck 
of hundreds of lentil-sized, rounded, brownish-red, smooth, 
glistening, disseminated, flat, or elevated tubercles. They 
were firm and elastic, slightly painful, and upon some of 
them were dilated bloodvessels. One or two other cases of 
the same kind have been reported by others. 

Lymphoderma Perniciosa. See Mycosis fungoides. 

Lymphosarcoma. See Sarcoma. 

Maculae et Striae Atrophicae. See Atrophoderma stria- 
tum et maculacum. 

Maculae Caeruleae. See Pediculosis corporis. 

Madura Foot. See Fungous Foot of India. 

Madesis or Maderosis is an obsolete term for thinning of 
the hair. 

Mai de la Rosa. See Pellagra. 

Mai Rosso. See Pellagra. 

Maladie des Vagabonds. See Pediculosis. 

Malignant Papillary Dermatitis. See Paget's Disease. 

Malignant Pustule. See Pustula maligna. 

Masque de la Grossesse. See Chloasma. 

Medicinal Eruptions. See Dermatitis medicamentosa. 

Melanoderma. See Chloasma. 

Melasma. See Chloasma. 



318 DISEASES OF THE SKIN. 

Melanosarcoma. See Sarcoma. 

Melanosis Lenticularis Progressiva. See Atrophoderma 
pigmentosum. 

Melitagra. See Pustular eczema. 

Mentagra. See Sycosis. 

Microsporon furfur is the parasite of chromophytosis, 
which see. 

Miliaria (Mi 2 l-i 2 -a'ri 2 -a 3 ). Synonyms : Sudamina ; 
Lichen tropicus ; (Ger.) Frieselauschlag ; Prickly heat. 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is 
enough to distinguish two forms, namely, sudamina, and 
lichen tropicus. 

Symptoms. Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile 
diseases, and occurs as an eruption of an immense number 
of small, closely crowded, but discrete, bright, pearly vesi- 
cles entirely without inflammation or subjective symptoms. 
They are most abundant on the trunk, especially upon its 
anterior plane, but may occur anywhere. After lasting a 
few days they are absorbed and disappear by drying up, 
possibly with some scaling. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 
pinpoint, bright-red papules (miliaria papulosa) ; or of very 
small vesicles upon an inflamed skin (miliaria rubra) ; or the 
eruption may be a composite one of papules interspersed 
with vesicles and pustules. Whichever form it may assume 
the lesions are present in great number, and closely crowded 
together, though not aggregated. It may involve the whole 
surface, but is most common on covered parts, and specially 
upon the trunk. The eruption is apt to become better or 
worse according to the changes in the temperature of the 
atmosphere. The disease may last in this way throughout 
the warm weather. It is no uncommon thing for furuncles 
to form, and even cutaneous abscesses. Itching, prickling, 



MILIUM. 319 

and burning are always annoying accompaniments. If the 
skin is much scratched, eczema may complicate the disease. 
The old nurse's " red gum," the strophulus of older writers, 
is a miliaria. Kaposi regards the disease as an eczema. 

Etiology. The cause of sudamina is retained sweat, 
owing, probably, to epithelium clogging up the sweat pores 
when sweating is stopped on account of the fever. Lichen 
tropicus is due to congestion about the sweat pores and irri- 
tion of the skin when profuse sweating is induced by too 
w r arm clothing and hot weather. It is also suggested that 
checking a profuse sweat may cause it. It is seen most 
commonly in babies and fat people. It is noticeable in this 
city (New York) that the children who live near the river- 
front and are a good deal in the salt water escape the dis- 
ease, while it is very common in the rest of the tenement- 
house population. 

Diagnosis. Sudamina differs from vesicular eczema by 
its sudden occurrence during a febrile process ; by being 
non-inflammatory ; by its vesicles not breaking down ; and 
by not itching. Lichen tropicus differs from eczema by the 
minuteness of its papules ; by its sudden appearance ; by 
not forming patches which are moist ; by having a high 
atmospheric temperature as an evident etiological factor, 
and by the tingling rather than the itching of the eruption. 

Tkeatment. Sudamina needs no treatment, as with the 
subsidence of the fever it gets well of itself. Lichen tropi- 
cus requires attention to the diet, cutting off the meat in 
children, and lessening its amount in adults. Cooling 
drinks, and the administration of gentle saline laxatives are 
also advisable. Locally, bathing in salt water or alkaline 
lotions, and subsequent powdering of the skin, conjoined 
w T ith wearing light clothing, and not using too warm bed- 
covers, will relieve and ofttimes cure the trouble. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. The 
epidemics have occurred most often in France. 

Milium (Mi 2 l-i 2 -u 3 my Synonyms : Grutum ; Strophulus 
albidus ; Acne albida ; Tuberculum sebaceum, 



320 DISEASES OF THE SKIN. 

Symptoms. These are small pinhead to split-pea sized, 
firm, whitish or yellowish, slightly elevated papules that 
occur usually upon the face. They are spherical in shape, 
and slowly increase in size up to a certain point, when they 
remain stationary. They give rise to no subjective sensa- 
tion. While their most common site is the face below the 
eyes, they may occur anywhere on the face ; and also upon 
the penis and scrotum. In this latter situation they are 
more decidedly yellow in color, flat, and often attain the 
size of a small bean. Along the corona glandis they are 
sometimes very thickly strewn. On the genitals of women 
their most frequent site is the labia minora. There may be 
but one or two, or a score of them. Occurring in the eye- 
lids they are called chalazion. When they undergo calca- 
reous degeneration (an infrequent occurrence), they form 
mtaneous calculi. Comedones are often present at the same 
time with milia. Any part of the body may be affected. 

Etiology. Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, such 
as pemphigus, erysipelas, or those in which destructive pro- 
cesses have taken place and cicatrices formed. They are 
often congenital. 

Pathology. They are supposed to be due to retained 
secretion on account of the upper layers of the stratum cor- 
neum growing over the openings of the sebaceous glands, 
or to a non- development of the glands. Robinson thinks 
that some of them are due to " miscarried embryonic epi- 
thelium from a hair follicle or from the rete," while those 
" following pemphigus, erysipelas, syphilis, and lupus con- 
sist of fatty epithelium and cholesterine, the epithelium 
being often arranged in concentric layers around a central 
fat nucleus." 

Treatment. The treatment consists in pricking the top 
of the papule and pressing out its contents. To make sure 
of the destruction of the growth a drop of carbolic acid or 
iodine may be introduced into the cavity remaining. Hard- 
away advocates electrolysis as being the speediest and best 
treatment. 

Mitesser. See Comedo, 



MOLLUSCUM CONTAGIOSUM. 



321 



Mole. See Nsevus. 

Molluscum Cholesterique. See Xanthoma. 

Molluscum Contagiosum (Mo'^-lu^k'uSm ko 2 n-ta-ji 2 -os r - 
u 3 m). Synonyms : Molluscum epitheliale, seu sebaceum, 
seu verrucosum, seu sessile ; Epithelioma contagiosum ; 
(Fr.) Acne varioliforme, Ecdermoptosis. 

Fig. 33. 




I Hi Are 




Molluscum. (After Allen.) 

Symptoms. This is a contagious disease of the skin 
that occurs in most cases upon the face and in children, and 
is characterized by the appearance of one or more rounded 
pearly white or pinkish discrete tumors, varying in size from 
a pinhead to large pea (Fig. 33). These tumors are waxy 



322 DISEASES OF THE SKIN. 

or opaque, and on top are slightly flattened, and show an 
umbilication or small depression, out of which the soft cheesy 
contents of the tumors can be squeezed. These tumors are 
at first very small, but gradually grow until they attain a cer- 
tain size, when they may remain unchanged for an indefinite 
period, or they may become inflamed, break down of them- 
selves, discharge their contents, and disappear either with- 
out leaving any trace or with a very slight scar. There are 
not infrequently scores of these tumors to be found on the 
same subject. They are commonly sessile, but may become 
more or less pedunculated. The genitalia, breasts, and 
scalp are affected next to the face in point of frequency, 
while the tumors may occur anywhere but on the palms and 
soles. 

Etiology. Children are far more often affected than 
adults. If adults show them it will usually be found that 
they are in attendance upon children who have the dis- 
ease. The bad hygienic conditions under which poor people 
live seem to predispose to the affection, as it is rare to 
meet with it among the well-to-do. There is little doubt 
but that the disease is contagious. Though inoculation ex- 
periments have failed in most instances, still there have 
been a few cases in which they have been successful. In 
the spring of 1891 a child with molluscum contagiosum 
came into my service in the Randall's Island Hospital, 
and within a few weeks, no attempt being made to destroy 
the tumors, there were six cases in the wards. 

Pathology. The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. One 
of the most characteristic features of the disease is the 
so-called " molluscum corpuscle," w T hich is but a changed 
epithelial cell (Fig. 34). These appear, under the micro- 
scope, as large, ovoid, lustrous bodies, without nuclei, some 
being either wholly or partly contained in an epidermic 
envelope, and some being entirely uncovered. Several 
parasites have been declared to be the cause of the disease 
by different investigators, the latest candidates being the 



MOLLUSCUM VERKUCOSUM. 323 

psorosperm of Darier in 1889, and the gregarine of Neisser 
in 1888. Torok 1 declares these to be merely artificial 
products of the methods used, and is sure that the disease is 
not due to a parasite. 

Fig. 34. 




Molluscum corpuscles. (After Kaposi.) 

Diagnosis. The appearance of the disease is so charac- 
teristic as to be diagnostic. It is most apt to be confused 
with milium, but if it is remembered that milia have no 
central depression, while mollusca have, the confusion will 
exist no longer. If they are taken for the vesico-pustule of 
variola, a scarcely probable occurrence, pricking their tops 
will at once show that they are not pustules, and if they are 
watched for a day or so it will be found that they remain 
unchanged. 

Treatment. The speediest way of getting rid of the 
tumors is to scrape them off with the curette. To insure 
their not returning it is advisable to touch the base of each 
tumor with a drop of carbolic acid, or a stronger acid. Or 
it is sufficient to make a small slit in the top of the tumor 
with a scalpel, and squeeze out the contents, and touch up 
the base. 

Molluscum Epitheliale. See Molluscum contagiosum. 

Mulluscum Fibrosum. See Fibroma. 

Molluscum Pendulum. See Fibroma. 

Molluscum Sebaceum. See Molluscum contagiosum. 

Molluscum Verrucosum. See Molluscum contagiosum. 

1 Monatshefte f. prakt. Dermat., 1890, x, 149. 



324 DISEASES OF THE SKIN. 

Monilethrix. See Nodositas crinium. 

Morbilli (Mo^b-Wli). Synonyms : Rubeola ; measles. 

This is one of the contagious exanthemata, which is 
characterized by marked catarrhal symptoms, such as con- 
junctivitis, coryza, and bronchial inflammation ; more or 
less fever, and constitutional disturbance ; and then, on 
about the third day, an eruption of small, red, flat papules 
that rapidly enlarge, and uniting with others form mulberry- 
colored little patches often of a crescentic shape, with areas 
of sound skin between. The eruption begins on the face 
and neck, spreading downward, from which it covers the 
whole body in about a day and a half. The fever begins to 
decrease on the second day of the eruption. The rash 
begins to disappear by the third or fourth day, and is 
gone by the ninth day. Furfuraceous desquamation follows 
the subsidence of the exanthem. Sometimes it is so slight 
as to be hardly noticeable, and it is never so marked as in 
scarlatina. 

Diagnosis. The only dermatoses with which measles is 
apt to be confounded are an erythema, and the macular 
syphilide. But the catarrhal symptoms ; the regular pro- 
gression of the eruption from above downward ; and the 
crescentic patchy arrangement and dark color of the lesions 
are sufficient to differentiate it. In erythema we may have 
some constitutional disturbance, but it is of short duration ; 
the eruption is more pronounced on the trunk and extremi- 
ties, and shows no order of progression ; the color of the 
eruption is a brighter red ; there is an absence of crescentic 
arrangement ; and very often an accompanying urethritis 
will suggest the ingestion of some of the balsams as a cause 
of the trouble. The erythematous syphilide affects the sides 
of the chest and the abdomen more than the face ; the rash 
lasts for weeks after any possible fever has passed ; its lesions 
have no definite arrangement and come out in successive 
crops, so that at the same time there will be present lesions 
of different age, and staining of the skin from those that 
have gone. 

Morbus Elephas. See Elephantiasis. 



MORPHCEA. 325 

Morbus Maculosus Werlhofii. See Purpura. 
Morbus Pedicularis. See Pediculosis. 

Morphoea (Mo 2 rf-e'a 3 ). Synonyms : Keloid of Addison ; 
Circumscribed scleroderma. 

A chronic, circumscribed hardening of the skin, forming 
an oval or irregularly shaped, smooth, lardaceous, yellowish 
patch, looking as if mortised into the skin, and tending to 
spontaneous recovery. 

Symptoms. This is one of the rarer forms of skin dis- 
ease, regarded by many as a circumscribed scleroderma. It 
occurs either as circumscribed, variously sized, oval or 
irregularly shaped patches ; or in the form of bands. The 
most common is the patchy form. It begins as a congested, 
red, rosy, or lilac macule, which enlarges, pales in the centre, 
becomes hardened, and assumes the form of a characteristic 
patch of the disease. This patch looks like a piece of old 
ivory or of lard set in the skin, being of a yellowish-white color. 
The color may be pinkish, yellow, brown, or even black. The 
skin over the patch is usually smooth, and easily pinched 
up. It may be wrinkled, or eroded in the centre. It may 
be level with the surface of the skin, or raised above it, or 
sunken below it. Around it is a lilac border due to dilated 
vessels. When the patch is pinched between the fingers 
it feels firm, like leather. There may be but a single 
patch, or a number of them. As a rule the disease is 
unilateral. After a varying length of time it may disappear 
spontaneously, although it may remain for a number of 
years. There are usually no subjective symptoms, and 
the disease remains unchanged until it disappears. In 
some cases it enlarges by new patches developing at the 
periphery of the old one and uniting with it. Exception- 
ally there may be some itching or pain, and ulceration may 
occur. Sensation is generally preserved. The band form 
is usually single, and may form a depressed sulcus or a 
raised ridge, looking much like a cicatrix. In addition to 
the bands there may be atrophic spots. 

The most common locations of morphoea are anywhere on 
the trunk, but specially on the breasts ; on the head and 



326 DISEASES OF THE SKIN. 

face in the parts supplied by the fifth nerve, and on the 
limbs. It is not infrequently associated with other nervous 
phenomena, and may occur along the course of a nerve, like 
zoster. Nettleship 1 has reported a case in the region of the 
first and second divisions of the fifth nerve with paralysis of 
the intra-ocular branches of the third nerve, which in time 
had associated with it hemi-atrophy of the whole of the left 
side of the head. There is no disturbance of the general 
health. The secretion of sweat over the patches may be 
normal, lessened, or absent. When the disease disappears 
it may leave no trace of itself, or it may be followed by pig- 
mentation or even permanent atrophy not only of the skin 
but also of the muscles. A form of leprosy has been 
wrongly named morphoea. 

Etiology. The disease is a neurosis that occurs at all 
ages after the second year. The victims of it are often neu- 
rotic. Prolonged worry or anxiety seems to predispose to 
it, and in some cases external local irritation seems to excite 
it. It is said that the band form is most frequently seen in 
children, and that females are more often affected than 
males. 

Diagnosis. Keloid may be mistaken for morphoea, but 
it has claw-like processes ; is more vascular and harder ; 
and lacks the old ivory color and the lilac surround- 
ing zone. Some forms of ancesthetic leprosy have been 
spoken of as morphoea, but they are markedly ansesthetic, 
and this will be sufficient for diagnosis. Leucoderma is a 
pigment change only, the skin being otherwise unchanged. 

Treatment. Unfortunately there is little or nothing to 
be done for the disease beyond attention to the general 
health of the patient. Arsenic may be of some benefit. 
Galvanism is perhaps the only local means that gives any 
promise of benefit, and that is but a feeble one. 

Prognosis. We can tell our patient that there is a strong 
probability that the disease will be recovered from in time, 
but we should be careful about giving a positive favorable 
prognosis. 

1 Trans. Clin. Soc. Lond., 1882-3, xvi. 199. 



MYCOSIS FUNGOIDES. 327 

Morpion is a name for the pubic louse. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, bullae, 
and fissures of the palmar side of the hands and fingers, and 
paronychia and necrosis of several phalanges. It is allied 
to, if not identical with, syringomyelia. 

Mother's Mark. See Naevus. 

Multiple Fungoid Papillomatous Tumors. See Mycosis 
fungoides. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by certain forms of flies, which lay 
their eggs under the skin. These subsequently hatch out 
and give rise to the dermatitis. 

Mycetoma. See Fungous foot of India. 

Mycosis Fungoides (Mi-ko'srs fu'n-goM'dez). Syno- 
nyms : Inflammatory fungoid neoplasm ; Multiple fungoid 
papillomatous tumors ; Fibroma fungoides ; Lymphadenie 
cutanee ; Granuloma fungoides ; Eczema hypertrophicum or 
tuberosum ; Ulcerative scrofuloderma ; Lymphodermia per- 
niciosa ; Sarcomatosis generalis ; Multiple sarcoma cutis ; 
Fungoid dermatitis ; Beerschwamahnliche multiple Papillar- 
geschwiilste der Haut. 

A chronic progressive disease of the skin, characterized 
by the appearance, with or without an antecedent erythema- 
tous or eczematous stage, of fungating tumors, that tend to 
break down and ulcerate. It leads, through marasmus, to 
death. 

Symptoms. The many names that have been applied to 
this rare disease testify to the uncertainty of our knowledge 
of its proper place in the classification of skin diseases. It 
assumes so many forms that it is impossible in our limited 
space to give a complete picture of the disease. In some 
cases the first thing noticed is what appears to be a simple 
eczema, erythema, urticaria, or psoriasis in variously sized 
patches, and accompanied by marked pruritus. These 
lesions occur anywhere, and constitute the first stage of the 
disease. After some months, or two or three years or more, 
the patches become raised, glistening, and infiltrated, more 



328 DISEASES OF THE SKIN. 

deeply red, and pea-sized papules form. These disappear, 
and new ones form. This is the second stage, and may last 
months or years. Then the characteristic tumors form 
either by the papules enlarging and coalescing, or as tumors 
at once rising out of the sound skin, without antecedent 
erythematous stage. The tumors are oval, hemispherical, 
or irregular in shape, sharply defined, sometimes slightly 
pedunculated. They are of bright-red, bluish-red, or dark- 
red color. Sometimes hard and elastic, sometimes soft and 
succulent. The epidermis over them is tense, thin, and 
glistening. They may be absorbed and disappear, new ones 
appearing ; or they may become necrotic and ulcerate. In 
size they vary from that of a pea to that of the fist. At 
first they occur only on the trunk, later they come any- 
where, and involve even the mucous membrane of the 
mouth. The itching and pain continue well into the tumor 
stage, when they lessen. The lymphatic glands enlarge 
painlessly. The hair falls from over the tumor. The gene- 
ral health of the patient is undisturbed for a long time, but 
at last a general marasmus sets in and the patient dies, 
usually from an uncontrollable diarrhoea or some complica- 
tion on the side of the lungs. There has been but one case 
of recovery reported. 

Etiology. The majority of the cases have been women 
over thirty years old. The disease is held not to be con- 
tagious. Blanc 1 found in one case that there was a marked 
reduction in the white blood-corpuscles, their proportion to 
red being 1 to 130, instead of 1 to 350 or 500. This is 
about all that is known of the etiology of the disease. 
While much study has been given to the pathology of the 
affection there is no agreement among pathologists as to the 
essential nature of the disease. 

Diagnosis. The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot be 
made with certainty. There is something peculiar in the 
sharply circumscribed outline, and the chronicity of the 
eczematous patches, and an unusual location and pertinacity 

1 Journ. Cutan. and Gen.-urin. Dis., 1888, vi. 256. 



MYXCEDEMA. 329 

about the psoriatic patches that would suggest the possi- 
bility of mycosis fungoides. When the tumors develop, and 
the capricious manner of their coming and going is observed, 
the diagnosis is more evident. 

Treatment. Thus far nothing has been found to stay 
the course of the disease, except that Kobner reports a 
cure of a case by means of hypodermic injections of arsenic. 
A general tonic treatment is always indicated. Locally, 
pyrogallol; ichthyol ; mercurial ointment ; injections of car- 
bolic acid; resorcin, and camphorated naphthol have been 
used and may be tried. The itching is most rebellious 
to treatment. The tumors, when not in great numbers, 
may be cut out, though the operation is of doubtful utility. 
The ulcerations that result from breaking down of the 
tumors must be treated on surgical principles. 

Mycosis Microsporina. See Chromophytosis. 

Myoma (Mi-o'-ma 3 ). Like most of the tumors, so this 
one concerns the surgeon more than the dermatologist. 
Myomata may be single or multiple. The latter is very 
rare. They are composed of muscular fibres, and vary in 
size from a split-pea to an orange. They are painful on 
pressure, and sometimes spontaneously. They are pink, red, 
or normal in color, disseminated, or aggregated into patches, 
though still retaining their individuality. The epidermis 
over them is unchanged. The single tumors may be sessile 
or pedunculated, and may attain the size of an orange. 
They have their seat most often on the female breasts, and 
on the genitalia of both sexes. If they contain a good deal 
of fibrous tissue they are called fibro-myoma ; if they con- 
tain large bloodvessels, they form angio -myoma ; or, if the 
lymphatics are involved, we have lympliangio-myoma. 
Excision is the only thing that can be done for them. 

Myoma Telangiectodes. See Myoma (Angio-myoma). 

Myxoedema (Mi 2 x-e 2 d-e'ma 3 ). This is a constitutional 
disease with cutaneous symptoms. The skin becomes waxy 
pale ; yellowish ; shining in some places, dull and earthy- 
looking in others ; it is dry, scaly, exfoliating on the ex- 
tremities, sometimes ulcerated, and verrucose on the lower 



330 DISEASES OF THE SKIN. 

limbs. The fingers and toes are sometimes livid. There is 
partial or general alopecia, and deformity and fragility of the 
nails. There is a general oedematous swelling of the whole 
integument as well as of the mucous membranes, and this 
oedema does not pit on pressure. 

The disease affects women far more often than men, and 
involves all parts of the body. There is an enfeeblement of 
mind, and a great lowering of the sense of touch, taste, and 
smell ; a torpidity of movement and of the digestive func- 
tions. It ends fatally either by marasmus, or by complica- 
tions on the side of the internal organs. 

The diagnosis in the early stage is difficult ; when fully 
developed it could hardly be taken for anything else. The 
cause of the disease is unknown, and its treatment in- 
effectual. 

Nsevus (Ne'virV). Nsevi may be pigmentary or vascular. 

Nsevus Pigmentosus. Synonyms : Nsevus spilus ; Nae- 
vuspilosus; Nsevus verrucosus ; Naevus lipomatodes ; (Ger.) 
Fleckenmal, Pigmentmal, Linsenmal ; Pigmentary mole ; 
Mother's mark. 

A congenital, circumscribed hyperpigmentation of the 
skin, often accompanied by a growth of coarse hair, and 
hypertrophy of the connective and fatty tissues. 

Symptoms. These growths are closely allied to lentigo 
and chloasma, as a hypertrophy of pigment is a prominent 
feature of them. When they consist of pigment only, and 
are not raised above the surface of the skin, they are called 
ncevus spilus. When besides the pigment there is a hyper- 
trophy of the connective tissue, and they are raised and 
uneven, the name ncevus verrucosus is applied to them ; or 
ncevus lipomatodes if they are soft and contain fatty tissue ; if 
hair grows from either form, then we speak of ncevus pilosus. 
In color they vary from a light to dark brown or black. In 
size they vary from a split-pea to an area large enough to 
cover the whole back. Most commonly they are of small 
size. They may be located anywhere, though most often on 
the face, neck, and back. There may be but one or two, or 
hundreds of them. They may have no special distribution, 



JST^VUS VASCULARIS. 331 

or they may follow nerve-tracts. They may be unilateral or 
bilateral, and sometimes symmetrical. If hair is in them it 
is coarse and stiff, and generally darker than that of the 
head. Sometimes large hairy moles bear a strong resem- 
blance to the fur of animals. They grow in proportion to 
the growth of the individual, and cease growing when he 
has attained his growth. They are usually congenital, but 
may be acquired, and are liable to undergo malignant change 
in advanced life. They give rise to no subjective symptoms. 
They are permanent growths. They rarely disappear of 
themselves. 

Etiology. To account for the appearance of these mal- 
formations we have only the theory of nerve influence, and 
that is by no means satisfactory. Their popular name of 
mother's mark shows that the popular superstition agrees 
with the scientific theory. We can simply regard them as 
anomalies. 

Diagnosis. Moles differ from lentigo in being congeni- 
tal and permanent, and in a hypertrophy of connective 
tissue and a growth of hair being connected with them. 
The difference between hairy moles and hypertrichosis is in 
the substratum ; in the latter the underlying skin is other- 
wise normal. 

Treatment. We can destroy these growths and leave 
behind but little scar. If there is but a single pigmentary 
mole it may be cut out. In this case it will leave a linear 
scar. It is generally better to destroy the growth by touch- 
ing it over carefully with nitric or acetic acid. This is done 
by stippling, as it were, making a row of dots in this 
fashion — 



Electrolysis by multiple puncture, or by transfixing the 
mole in various directions, is a sure and speedy way. Hairy 
moles are best destroyed by electrolysis as in superfluous 
hair, only here a coarser needle must be used, as we are 
not so particular about a little scarring. 

Naevus Vascularis. Synonyms : Nasvus vasculosus seu 
sanguineus ; Angioma ; (Grer.) Feuermal, Gefassmal ; 



332 DISEASES OF THE SKIN". 

(Fr.) Tache de feu, Tache vasculaire ; Port-wine mark ; 
Birth-mark ; Claret stain. 

Symptoms. These are composed mainly of vascular tis- 
sue, and are congenital or appear during the first month of 
life. They are usually single, but may be multiple. They 
vary greatly in size, shape, and color, but all possess one 
feature in common — they pale under pressure. They may 
be pinhead spots not raised above the surface of the skin, or 
they may form large, erectile, elevated, pulsating tumors, or 
they may spread out so as to involve a large area. They 
may be pink, bright-red, dark-red, or even purple in color. 
When on the face they become more pronounced on crying, 
coughing, and the like. They may disappear spontaneously ; 
increase in size during a few months or years ; or, most 
commonly, remain unchanged. According to their size 
they have received various names. The small, flat or scarcely 
raised nsevus composed of capillaries is called ncevus sim- 
plex or capillary ngevus. This is the form very often seen 
in children. It is not infrequent for it to disappear of itself 
after a while, either leaving no trace, or a delicate atrophic 
scar. When it is so large as to form a patch as big as the 
hand or larger, it is called ncevus flammcus or port-wine 
mark. The surface of this form is often uneven, and studded 
with small, erectile vascular tumors, or, may be, moles. The 
large, erectile, pulsating tumors are called ncevus tuberosus, 
angioma cavernosum, venous ncevus. They differ very much 
from the other forms in appearance and formation. Their 
surface is uneven and lobulated. This form is apt to in- 
crease in size, and may attain enormous dimensions. 

Ngevi may occur anywhere on the body, but are most fre- 
quent on the head and face. They may also occur upon the 
mucous membranes primarily or secondarily. The back, 
nates, pudenda, and lower limbs are said by Crocker to be the 
most common sites of the cavernous form. All forms of 
nsevi made be hardly perceptible at birth, but become 
gradually more evident afterward. 

Etiology and Pathology. Vascular nsevi are probably 
always congenital malformations, though their appearance 
upon the skin may be retarded for some time. The simple 



N^IVUS VASCULARIS. 333 

capillary nsevi, which includes the port-wine marks, are 
simply an increase in number and size of the capillaries. 
In the venous nsevi we have also a new growth of connec- 
tive tissue forming a mesh- work, and they are supplied 
directly by an artery without the interposition of capillaries. 
Women are more prone to them than are men. 

Diagnosis. There can be no difficulty in diagnosis, 
excepting that a ncevus may be taken for a telangiectasis. 
This error would be of little consequence, since the latter is 
simply an acquired nrevus, and differs chiefly in having a 
central red point from which the dilated capillaries radiate. 

Treatment. Electrolysis is the best means for destroy- 
ing the vast majority of these growths. The best way to 
use it in capillary nrevi and port-wine marks is by making 
multiple punctures in parallel rows, perpendicularly to 
the skin and down though its entire thickness. To ex- 
pedite matters one may use either a circle of needles set in 
a handle, or a row of three needles. Of course, the nega- 
tive pole is to be connected with the needle- holder, and 
the operation is to be conducted in the same way as in 
removing superfluous hair. By this method it is possible 
to entirely destroy small nsevi, and to very much diminish 
the unsightly appearance of large port-wine marks. As 
electrolysis necessarily destroys the skin, we must leave a 
scar. But this is less conspicuous than the nsevus, and if 
the operation is carefully done the scar is soft, smooth, and 
pliable. There is also much less danger of a deforming 
scar from the use of a single needle than from a group of 
them. Therefore this method is preferable, though more 
tedious. The punctures must not be made close together ; 
at least a sixteenth of an inch should be left between 
them. After the na?vus has been carefully gone over, it 
should be left alone for a couple of weeks or more for the 
full effect of the operation to be seen. It can be gone over 
again, and another interval of time allowed, and so on till 
the growth is destroyed as much as possible. 

Beside electrolysis we may use multiple scarifications ob- 
liquely to the skin. Or we may use the ethylate of sodium 
freshly prepared and applied to the absolutely dry skin, 



334 DISEASES OF THE SKIN. 

using a brush or glass rod. To avoid scarring, only a small 
part of the naevus must be attacked at a time. A crust will 
form, which must be left to come away of itself. Fuming 
nitric acid or the acid nitrate of mercury may be stippled 
over the growth. Or vaccination may be performed over 
them. Or multiple punctures may be made by means of a 
steel needle dipped in nitric or carbolic acid. Marshall 
Hall advocates breaking up the nsevus by introducing a 
cataract-needle close to the edge of the growth, pushing it 
across to the opposite side, then nearly withdrawing it, and 
again pushing it in at a little distance from the first 
puncture. But electrolysis is the best and most controllable 
method. 

For cavernous nsevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the hope 
of striking the deep vessels, It is well, sometimes, to pass 
the needle from the edge deep under the naevus and clear 
through to the other side, let the current pass for a half 
minute, partially withdraw the needle, and again push it in 
another direction. Some prefer introducing two needles, 
connected each with one pole of the battery, in opposite 
directions. A platinum or gold needle must be used with 
the positive pole. Excision may be performed, but some- 
times this gives rise to alarming hemorrhage. Multiple 
punctures with a red- hot steel shoemaker's awl, or the point 
of a Paquelin or galvano-cautery heated to a dull red, are 
other good methods of treatment. It has been proposed to 
use a metallic plate perforated with a number of holes with 
which to exercise strong pressure upon the mevus w T hile the 
galvano-cautery is introduced through the holes. Injections 
of carbolic acid, perchloride of iron, alcohol, and the like, 
are effectual, but dangerous methods. Setons are not used 
as much as formerly. Compression by an elastic bandage 
is at times curative when the nsevi are located over bony 
prominences. 

As many capillary nsevi in children disappear in time it 
is advisable not to interfere with them at once, contenting 
ourselves with painting them with collodion and waiting 
until the child is old enough to desire their removal. Of 



NODOSITES NON-ERTTHEMATEUSES. 335 

course, if they are very unsightly we cannot wait, nor should 
we temporize with cavernous nsevi. In children one works 
most comfortably by using an anaesthetic, but it is not abso- 
lutely necessary. Keloidal scars may be an unfortunate 
accident in some cases. 

Prognosis. The prognosis should be guarded, and the 
cases carefully watched. All naevi may increase in size, 
though very many remain stationary. 

Naevus Araneus. See Telangiectasis. 
Narbengeschwulst. See Keloid. 
Narbenkeloid. See Keloid. 
Nerven Naevi. See Ichthyosis hystrix. 
Nesselausschlag. See Urticaria. 
Nettlerash. See Urticaria. 
Neuralgia Cutis. See Dermatalgia. 

Neuroma Cutis is an exceedingly rare disease of which 
but few cases have been reported. Neuromata are small, 
flat, firm tumors firmly imbedded in the skin. They are 
painful spontaneously and on pressure. The pain may be 
paroxysmal in character. They are relievable by surgical 
interference with the nerve. 

Neuropathic Papilloma. See Ichthyosis hystrix. 

Nodosites Non-erythemateuses des Arthritiques. Brocq 
applies this name to cutaneous and subcutaneous tumors that 
he has met with in connection with the gouty diathesis. 
They are of two varieties. The first one he calls Epheme- 
ral cutaneous nodules. They occur upon the forehead and 
form ill-defined elevations of the skin, of small pea to hazel- 
nut size, and entirely painless. They are movable with the 
skin, though sometimes they are adherent. They appear 
first during the night and disappear within twenty-four 
hours. 

The second variety is the subcutaneous rheumatismal 
nodule. It forms a small tumor resembling a gumma. 
The skin slides freely over them in most cases. The color 
of the skin is unchanged. They are firm and elastic to the 
touch. Generally they are painful on pressure, at times 



336 DISEASES OF THE SKIN". 

spontaneously. In size they vary from a pea to an almond, 
and they are sharply defined. They may remain for days 
or weeks, when they disappear, leaving no trace. They 
often come in successive outbreaks. Their seat of predilec- 
tion is about the joints, and upon the fibrous tissues that 
cover the superficial bones. They are generally discrete, 
and often very numerous. Their appearance often coin- 
cides with symptoms of pericarditis or pleurisy. Their 
treatment is that appropriate to the rheumatism that seems 
to be their cause, especially iodine and the iodides. 

Noli Me Tangere. See Lupus vulgaris. It has been 
used as a synonym for rodent ulcer. (Crocker.) 

Non-parasitic Sycosis. See Sycosis. 

Nodulus Laqueatus is that condition of the hair in which 
it seems to tie itself into knots. The hair is usually dry 
and curly. It is probably caused by handling of the hair, 
and does not occur spontaneously. 

Norwegian Itch. See Scabies. 

(Edema Cutis, Acute Circumscribed. It is a question 
whether this is a form of urticaria or not. It is certainly 
allied to it in the suddenness of its onset ; in the attending 
erythema, and digestive or other constitutional disturbances ; 
and in the character of its lesions. It differs from urticaria 
in being recurrent in the same locations ; in the shading off 
of the swellings into the surrounding skin ; and in being 
unattended by itching. It is prone to occur upon the face, 
and there often closes up one or both eyes in an enormous 
swelling ; or the lips so that the mouth cannot be opened. 
In the present state of our knowledge it is probably well 
to regard it as urticaria cedematosa. (See Urticaria.) 

(Edema Neonatorum. This disease was formerly con- 
founded with sclerema, but quite recently has been separated 
from it. 

Symptoms. It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema spreads 
upward along the thighs, shows itself upon the hands, 
then upon the genitals and back. It is hard and pits only 
on deep pressure. The skin is of a violaceous red, or more 



ONYCHAUXIS. 337 

or less intense yellow, and feels cold. The infant is coma- 
tose; its pulse is feeble ; its breathing labored; and its cry 
sharp. A high temperature may exceptionally be present. 
Death usually results on account of some pulmonary affec- 
tion, or from collapse. Exceptionally, recovery takes place. 

Etiology. The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered, or exposed to poor 
hygienic surroundings. 

Diagnosis. It differs from sclerema in being more 
limited to certain localities ; in the skin being more livid 
from the first, and not so hard ; in affecting the dependent 
parts ; and in lacking the stiffness of the joints (Crocker.) 

Treatment. Though the prognosis is exceedingly bad, 
an attempt should be made to nourish the child as well as 
possible by artificial feeding ; it should be wrapped in 
flannel and kept warm ; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 

(Eil de Perdrix. A soft corn. 

Oligamie. Anaemia. 

Oligosteatosis. Deficiency of fat secretion. 

Oligotrichia. See Alopecia. 

Onychatrophia. See Atrophia unguium. 

Onychauxis (0 2 n-i 2 k-a*x'i 2 s). Onychogryphosis (0 2 n i 2 k- 
o-gri 2 f-o r -si 2 s). These are both hypertrophies of the nail 
either in length, breadth, or thickness ; or in all at the same 
time. When the growth is markedly forward, and the nail 
is much thickened, it is called onychogryphosis. The nail 
in these instances generally turns to one side after reaching 
a certain leno-th, sometimes so much so that a bio- toe-nail 
may lie over the second and third toes. If the hyper- 
trophy is lateral we are apt to have onychia, ingrowing 
toe-nail. The hypertrophied nail is rugous, but highly 
polished, brown, and there is often an accumulation of 
scales under it which at times °:ive rise to a bad odor from 
decomposition. The toe-nails are those most often hyper- 
trophied, but the finger-nails may be so affected. 

15 



338 DISEASES OF THE SKIN. 

Etiology. Badly fitting boots and neglect of proper 
care of the nails are causes of onychauxis, and onychogryph- 
osis. They often arise without discoverable causes. They 
may be due to a congenital predisposition. They very 
often occur as part of other chronic skin and constitutional 
diseases, such as eczema, psoriasis, leprosy, syphilis, and 
ichthyosis. The thickening may be due to disease of the 
matrix or to a thickening of the horny layer only. 

Treatment. The hypertrophied nail may be removed 
by mechanical means such as by the file, saw, or knife. The 
continuous use of salicylic acid sometimes will cause the 
thickened mass to fall off. The oleates of tin and lead ; 
the continuous wearing of rubber cots ; and liquor potassre, 
are also efficacious in softening the thickened mass of the 
nail. The action of all these agents is assisted by daily 
removing the softened layers by mechanical means. When 
the hypertrophy is but a part of some other disease, it will 
be benefited by the same means as will benefit the cause 
from which it arises. If it is due to an inflammatory dis- 
ease of the nail-bed or matrix, that must receive attention. 
(See Onychia and Paronychia). After the nail deformity 
has been overcome it may return. 

Onychia (0 2 n-rk'i 2 -a 3 ) or Onychitis (0 2 n-i 2 k-i'ti 2 s). By 
this is meant acute inflammation of the matrix and nail-bed. 
The end of the finger or toe is reddened and swollen, and 
there is more or less throbbing pain. The nail is lifted from 
its bed, more or less pus escapes from underneath it, and it 
is eventually shed. The inflammation often spreads to the 
adjacent parts of the finger, and then we have that condi- 
tion commonly called Cl whitlow." When the nail falls, a 
spongy nail-bed is left, often with exuberant granulations. 
Under proper treatment a good nail may be reproduced, 
though in many cases either a very much deformed one will 
result or one that differs somewhat in appearance from the 
other nails. In some cases, instead of this phlegmonous 
form we have a dry inflammation that is known as onychia 
sicca. Here the nail is discolored, its edge thickened and 
brittle, its surface rough and more or less pitted. Eventu- 
ally the nail is shed. This condition is met with most often 



paget's disease of the nipple. 339 

in syphilis. A chronic onychia is occasionally seen, and is 
one of the causes of onychauxis. 

Etiology. Onychia is due to traumatism or to some other 
disease of the skin, such as syphilis, eczema, psoriasis, para- 
sitic diseases, dermatitis exfoliativa, and the strumous state. 

Treatment. The treatment of onychia varies with the 
stage of the disease and with the cause. Occurring as part 
of some general disease of the skin, the treatment appro- 
priate to the general disease will be beneficial to the onychia. 
Arising as an independent disease, or resulting from trau- 
matism, the application of a 10 to 20 per cent, resorcin 
ointment or plaster will often abort the disease in an early 
stage. If the disease has gone on to suppuration, surgical 
procedures will have to be resorted to, such as splitting of 
the nail or its removal as a whole, and subsequent dressing 
with iodoform, aristol, or a bichloride solution. 

Onychomycosis (0 2 n rk-o-mi-ko'-srs). This term means 
the invasion of the nail by a fungus, such as the trichophyton 
or favus, which see. 

Orticaria. See Urticaria. 

Osmidrosis. See Bromidrosis. 

Pachydermatocele. See Dermatolysis. 

Pachydermia. See Elephantiasis. 

Paget's Disease of the Nipple. Synonyms : Mamillaris 
maligna ; Malignant papillary dermatitis ; Epitheliomatose 
eczematoide de la mamelle (Besnier). 

Symptoms. This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 1 

It usually occurs in women over forty years of age, and at 
first has the appearance of an eczema madidans ; that is, it 
presents " a florid, intensely red, raw surface, very finely 
granular, as if the whole thickness of the epidermis had been 
removed. From such a surface, on the whole or greater 
part of the nipple and areola, there is always a copious, 
clear, yellowish, viscid exudation." Besnier believes that 
its primary stage is a keratosis, which, under any irritation, 

1 St. Bartholomew's Hospital Keports, vol. x. p. 83. 



340 DISEASES OF THE SKIN. 

assumes an eczematous appearance. The edge of the patch 
is sharply defined and slightly raised. Sometimes, instead 
of the raw surface, we have crusting, or even scaling. 
Telangiectases may be seen here and there. After months 
or years marked induration is manifest, pinching up the 
patch imparting the sensation, as described by Mr. Morris, 
of "a penny felt through a cloth." Burning or itching is 
complained of, which makes the disease the more nearly re- 
semble an eczema. But it does not yield to the ordinary 
treatment of eczema, and its border gradually extends. The 
female breast, usually the right one, 1 is the part most often 
affected, and there it always begins at the nipple, spreading 
thence over the areola and skin. After a few months, or not 
until twenty years, signs of scirrhous cancer appear. The 
nipple becomes more and more retracted and ulcerated. 
Hard nodules develop in the raw surface or deep down in 
the skin. The mammary gland itself may become affected. 
The cancerous cachexia develops later with ganglionic en- 
largements. Crocker has met with it on the scrotum. 

Pathology. It is still an open question whether the 
disease is malignant from the start, or, beginning as a sim- 
ple inflammation, becomes malignant, just as we find epi- 
thelioma of the tongue developing upon a leucoplakia. 
Darier and Wickham believe that the disease is due to 
psorosperms (see Psorospermosis). But their theory has not 
been generally accepted as yet. 

Diagnosis. Though very important, it is exceedingly 
difficult at first to make a positive diagnosis of a case of 
Paget's disease, from an eczema. Eczema, of the nipple is 
very common during the childbearing period, while Paget's 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating sur- 
face of Paget's disease, while we do have more variation in 
the course of the disease, exacerbations and seasons of ap- 
parent quiescence. In eczema the patch is not so sharply 
defined, and its border is not raised; about it there are apt 
to be outlying pustules or vesicles, and there is not the 

1 Wickham : Maladie de Paget, Paris, 1890. 



PANARIS NERVEUX. 341 

papyrus-like induration. When the nipple becomes re- 
tracted and ulcerations take place, together with shooting 
pains and enlarged lymphatics, the diagnosis is easy. 

Treatment. At the beginning, and while the diagnosis 
is still doubtful, the usual remedies for eczema should be 
tried. If these fail, as they will if the disease is not 
eczema, or if the right diagnosis is arrived at, powerful 
caustics must be used, if the disease is still superficial. We 
may use, as recommended by Darier, a solution of chloride 
of zinc, one in three, to produce an exfoliation of the dis- 
eased epidermis, and follow it with a mercurial plaster, 
alternating with iodoform or aristol. Or, a zinc paste may 
be kept on, spread thickly on lint, for four to six hours, and 
the slough poulticed off or allowed to separate under wet 
boric lint, under oiled silk, as recommended by Crocker. 

The paste used in the Middlesex Hospital is made as fol- 
lows : 

R. Zinci ohlorid., £>iv; 7 50 

Liq. opii sed., g iv ; 7 50 

Amyli, HJss; 3 

Aquse, Jj , 30 M. 

Ft. pasta. 

When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed antisep- 
tically. When nodules have formed and there is marked 
induration under an ulcerated surface, the whole diseased 
surface must be freely excised or the breast removed entire. 
If an operation or the use of caustics is unadvisable for 
any reason, relief to the pain and discomfort may be had 
by dressing with a fuchsin solution 1 per cent, strength. 

Panaris Nerveux of Quinquaud belongs to that group 
of obscure diseases in which stand Morvan's disease and 
syringomyelia. It is characterized by swelling of the ex- 
tremities, slight redness, and attacks of intense pain, ter- 
minating in eight to fifteen daj^s by fissure of the finger-end 
and fall of the nail. Sometimes the skin of the finger-end 
becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant application of 



342 DISEASES OF THE SKIN. 

chloroform liniment, and of irritant lotions or frictions to 
the cervical region and along the course of the nerves sup- 
plying the parts. Internally, he advises the valerianate of 
ammonia or of quinine. 

Panaritium. See Paronychia. 

Papilloma (Pa 2 p-i 2 l-lo'ma 3 ). By this term is meant a 
papillary outgrowth from the skin. Such are common 
warts, verrucous eczema, papillary excrescences following 
ulceration, Kaposi's dermatitis papillaris capillitii, ichthy- 
osis hystrix, and the like. The term is, therefore, of un- 
certain significance. Some authors have described papillo- 
mata apart from the above - designated diseases, and 
Hardaway reports at length a case of general idiopathic 
papilloma in a seven-months-old child. Mental defects have 
been noted in some of these cases. A muco-purulent secre- 
tion often is present, welling up between the papillae. The 
condition is a rare one. Under the name of papilloma area 
elevatum Beigel has described one of these rare cases. 

Papilloma Neuroticum. See Ichthyosis hystrix. 

Parasitic Diseases. The diseases of the skin caused by 
well-accepted parasites may be divided into two classes : 
1. Those due to vegetable parasites. 2. Those due to animal 
parasites. 

Group 1 comprises favus, ringworm, chromophytosis, ery- 
thrasma, and pinta. These will be found described under 
their proper headings. 

Group 2 comprises a large variety of parasites. Scabies 
and pediculosis, due respectively to the acarus and pedicu- 
lus, are described at length in this book. Besides these we 
have — 

The leptics autumnalis, harvest-bug, or mower's mite, 
that bores its head into the skin, causes great itching, and 
induces violent scratching and consequent excoriations. 

The demodex folliculorum is described in relation with 
the comedo. 

The pulex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up in- 



PARONYCHIA. 343 

flammation and, perhaps, ulceration and gangrene, and has 
to be dug out of the skin with a blunt needle. 

The pulex irritans y or common flea, whose ravages are so 
well known as not to require description. 

The dmex lectularius, or common bedbug, attacks the 
skin for its food, punctures it, and at the same time injects 
an irritating fluid to increase the hyperemia and his food 
supply. A wheal, or raised red spot with a central punc- 
ture, follows the bite, and a purpuric spot results. The ir- 
ritation is relieved by any of the means serviceable in urti- 
caria. 

Gnats and mosquitoes are too familiar to all of us. 

Ixodes, or wood-ticks, the filaria sanguinis and filar ia 
medinensis, the tcenia solium, and the echinococcus all find 
lodgment at times in the human skin. These parasites do 
not exhaust the list, but are the principal ones. 

Parasitare Bartfinne. See Trichophytosis barbae. 

Parasitic Mentagra. See Trichophytosis barbae. 

Parasitic Sycosis. See Trichophytosis barbae. 

Parchment Skin. See Atrophia cutis. 

Paronychia (Pa 2 r-o 2 n-i 2 k'-i 2 -a 3 ). This affection is popu- 
larly known as a whitlow, run-around, or ingrowing toe-nail. 
Ingrowing toe-nail results from the nail shoving, or being 
shoved into the soft parts, either on account of disease of 
the nail itself, or of ill-fitting shoes, or of injury. The big 
toe-nail, at its inner or outer edge, is the most common site 
of the disease, though any toe may be affected, and even the 
finger mav suffer. The furrow, fold, and bed of the nail 
all become inflamed, ulcerated, and exquisitely tender, dis- 
charging more or less pus. It is said to be more common 
in young people than in old, and far more frequent in men 
than in women. Paronychia of either the ulcerative or 
non-ulcerative form is frequently met with in syphilis. 

Treatment. Severe cases of paronychia most often find 
their way to the surgeon's hands. In syphilitic paronychia 
general anti-syphilitic treatment is required. In the non-ulcer- 
ative form mercurial ointment, diluted with one or two parts 
of diachylon ointment, may be used, or the mercurial plas- 



344 DISEASES OF THE SKIN. 

ter. In the ulcerative form, the parts should be cauterized 
with nitric acid or a strong solution of acid nitrate of mer- 
cury, followed by water dressings. Afterward the part 
may be dressed with iodoform or aristol. Bandaging, strap- 
ping with mercurial plaster, and the use of rubber cots are 
also useful methods of treatment. 

In ingrowing toe-nail the nail should be filed down the 
middle, or, if that does not relieve the pressure, it may have 
to be removed, in part or entire. The insertion of borated 
lint between the nail and the nail-fold, or using boric acid 
in powder first and some threads of lint or a little absorbent 
cotton to separate the parts, and strapping the toe with ad- 
hesive plaster, will also answer well. If ulceration has taken 
place, the ulcerated surface should be dressed with iodoform 
or aristol. If the ulceration should be covered with exu- 
berant granulations, they should be touched with the nitrate 
of silver stick. As a preventive of the trouble, wearing 
well-fitting shoes and keeping the nails clean and cut down 
the middle are the best means at our command. 

Paxton's Disease. See Tinea nodosa. 

Pediculosis (Pe 2 d-i 2 k-u 2 l-o r -si 2 s). Synonyms : Phthiri- 
asis ; Morbus pediculare ; Pedicularia ; Lousiness. 

Symptoms. There are three varieties of lice that infest 
the human species, namely, the pediculus capitis, pediculus 
vestimentorum, and pediculus pubis. Though they all be- 
long to one family, they differ among themselves, and have 
distinct regions which they invade. 

The pediculus capitis infests the head only, and of that 
the occipital region is the seat of invasion. From there it 
generally spreads to the parietal region, whicli is one of the 
best places in which to seek for nits, and, maybe, all over the 
scalp. The lice cause irritation of the scalp both by their 
movements and by the insertion of their haustellum into the 
follicles of the skin for feeding purposes. The louse has no 
mandibles. There is no such thing as a louse-bite. They 
simply suck their nutriment by inserting their haustellum 
into the follicles of the skin. The victim scratches to re- 
lieve the itching and irritation, and this gives rise to a 



PEDICULOSIS. 345 

dermatitis of eczematous character with the production of 
large pustules. A fully developed and characteristic case 
shows the hair in the occipital region matted together with 
a sticky secretion and, maybe, blood-crusts, more or less 
eczematous lesions and scattered pustules over the whole 
scalp, enlarged lymphatic glands in the neck, and perhaps 
a few small pustules on the neck and face. When a patient 
presents himself with a pustular eruption on the neck, ped- 
iculosis capitis should always be suspected, and search made 
for the pediculi or their nits upon the occipital and parietal 
regions. Very often no pediculi can be found, but, if the 
disease is pediculosis, the nits will be discovered in the 
localities mentioned. 

The pediculus vestimentorum, or body-louse, inhabits the 
seams of the clothing, where it lays its eggs, and which it 
leaves only for the purpose of feeding upon the skin. It 
inserts its haustellum into the follicles of the skin, and thus 
produces a small hemorrhagic spot, even with the surface of 
the skin, which is a pathognomonic lesion of the disease. 
This feeding gives rise to itching, and the victim scratches 
to relieve it, thus producing a second symptom, excoriations. 
These have one peculiarity, which is that they are very apt 
to take the form of long, parallel scratch-marks, because the 
patient digs into his skin with all four nails at once. More- 
over, as the lice live by preference in the shirt-band at the 
back of the neck, these long scratch-marks are most often 
seen over the shoulders. Whenever they are seen we should 
suspect lice. Excoriations are also seen on the inside of the 
limbs in locations corresponding to the seams of the clothing. 
In certain individuals, besides excoriations and hemorrhagic 
specks, we will find ecthymatous pustules, ulcerations, and, 
in very old cases, a great deal of pigmentation, so that the 
skin appears as if affected with a general chloasma. Any 
of these symptoms, hemorrhagic specks, excoriations, and 
itching, which is incessant in pronounced cases, should lead 
us to suspect lice, and a careful search of the seams of the 
clothing will reveal them, unless the patient has changed 
everything before coming to us. It must be remembered 

15* 



346 DISEASES OF THE SKIN. 

that the lice dwell both in the linen and woollen clothing, 
and, in bad cases, in the bedding also. 

The pediculus pubis, crab-louse or morpion, has a far 
wider feeding range than the other varieties. Though its 
favorite feeding-ground is the pubic region, it may be met 
with upon the hair of the abdomen, chest, axillae, beard, 
eyebrows and eyelashes. Itching, excoriations, and eczema- 
tous lesions are -the symptoms it gives rise to, though the 
disturbance is not so great as that caused by the other forms 
of lice. It is the least common variety. It requires care- 
ful search and a sharp eye to discover the vermin at times, 
as they are almost transparent, and usually are attached to 
the hairs head downward, and close to the skin. Cobbold 
taught that the pediculus that inhabits the eyelashes was a 
distinct species, the pediculus palpebrarum ; but by most 
authorities the distinction is not made. In some cases, in- 
stead of red punctate marks, we find dull or slaty gray, or 
pale-blue, lentil to split-pea-sized macules scattered over the 
pubes, abdomen, extensor surface of the arms, axillae, and 
inside of the thighs. These are known as maeulce eerulecB, 
or taches ombrees. They do not disappear on pressure, last 
for a few days, and then disappear of themselves. To give 
rise to these spots there must be a predisposition on the part 
of the skin. Most of the few reported cases have been in 
debilitated subjects. According to Duguet, 1 the macules 
are produced by the emptying of the contents of the salivary 
glands of the louse beneath the human epidermis. 

Etiology. All these diiferent varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig- 35) is 
about 2 mm. long and 1 mm. broad, with a triangular head 
and broad thorax and short legs. The body-louse (Fig. 36) 
is larger than the head-louse, being 2 or 3 mm. long, with 
a more oval head and longer legs with more developed claws. 
The pubic louse is broader and flatter than either of the 
others, with rounder head, longer, stronger, and more claw- 
like legs, resembling somewhat a crab (Fig. 37). The color 
of the lice is gray or white. They propagate with great 

1 Gaz. des Hop., 1880, liii. 362. 



PEDICULOSIS. 



347 



rapidity, the young hatching out in six or seven days, and 
being capable within eighteen days of propagating their 



Fig. 35. 




Pediculus capillitii. — Male. 
(After Kuchenmeister.) 



Fig. 37. 



Fig. 36. 




Pediculus corporis. 
(After Kuchenmeister.) 




Pediculus pubis. (After Schmarda.) 



species. It has been calculated that two female lice might 
become the grandmothers of 10,000 lice in eight weeks' 
time. The pediculi deposit their eggs close to the scalp 



348 



DISEASES OF THE SKIN. 



Fig. 38. 



ift 



S 



■a 



and secrete a glue-like substance that sticks the ova to the 
hair. There may be but one ova on a hair, or many of 
them. The distance of the nit from the scalp shows the 
length of time that the disease has existed. As it takes the 
hair about a month to attain the length 
of three-fourths of an inch, if we find 
the nit that distance from the scalp we 
know that it was deposited at least one 
month before. The severity of the symp- 
toms to which the lice give rise will 
vary with the individual, some people 
being far more susceptible than others. 
Infection takes place from other people 
or from infested body or bed clothing. 
Women and children are the most fre- 
quent victims of pediculosis capitis ; 
adults, and especially elderly people, of 
pediculosis vestimentorum. Pediculosis 
pubis is most frequently obtained from 
impure sexual intercourse, and is, there- 
fore, most common in young adults. 
Dirt and uncleanness favor all forms, 
though even the most cleanly may at 
times harbor vermin. 

Diagnosis. Pediculosis capitis needs 
to be diagnosticated from eczema. The 
characteristic location of its lesions upon 
the occipital region and nape of the neck, 
with its scattered and discrete large pus- 
tules over more or less of the scalp, 
should always suggest pediculosis ; then, 
if the lice or their ova are found by 
searching the hair, the diagnosis is es- 
tablished. Nits here, as elsewhere, are 
diagnosticated from epidermic scales by 
being located upon the side of the hair, while the scale 
has a hair passing through its centre (Fig. 38). The nit, 
too, is of a yellowish color, somewhat pear-shaped, with 
its larger rounded end upward, and it adheres closely to 



\ 



h 



Ova of head-louse 
attached to hair. (Af- 
ter Kaposi.) 



PEDICULOSIS. 849 

the hair, so as not to be readily removed. It is not 
always easy to distinguish pediculosis vestiuientorum from 
pruritus cutaneus, especially if at the time the patient 
presents himself he has clean clothes on throughout. Both 
may occur in elderly people, and both may last a long time 
with no other lesion than scratch-marks. In pruritus we 
may find evidences of atrophic skin changes; the itching is 
often paroxysmal, and made worse by the patient becoming 
overheated. If we find the parallel scratch- marks over the 
shoulders and the hemorrhagic specks, we can make a positive 
diagnosis of pediculosis. From urticaria pediculosis vestimen- 
torum differs in having hemorrhagic specks and in the parallel 
scratch-marks. Urticaria may complicate a pediculosis. 
Scabies differs from pediculosis in appearing by preference 
upon the anterior face of the wrists, upon the breasts in 
women, upon the penis of men, and about the waist-bands 
of both sexes. Its excoriations are not long, parallel 
scratch-marks, but small excoriations. If the lice or their 
ova can be found in any case the diagnosis of pediculosis is 
made easy. Dermatitis herpetiformis differs from pedicu- 
losis in wanting the parallel scratch-marks and in the mark- 
edly grouped character of its lesions. There will often be 
found groups of vesicles scattered about the skin. There 
can be no difficulty in diagnosticating the pediculosis pubis. 
Any itching there should lead to an investigation, which, if 
carefully made, will reveal the pediculi or their nits. 

Treatment. The most ready means of curing the dis- 
ease when in the hairy regions is to shave the hair off* and 
make some emollient application to the scalp to cure the 
eczema. But this is not advisable, excepting in children 
and in men in hospitals, and is not necessary, The most 
speedy and practicable method in public practice is to soak 
the head or pubic region in raw petroleum or kerosene, with 
or without diluting it with sweet oil. This may be done 
night and morning for two days and the parts then washed 
with soap and water. This will effectually kill all the lice, 
and probably destroy the life of the ova. The latter must be 
removed for fear that they are not dead, and for this pur- 
pose we may use the fine-toothed comb to the hair or pull 



350 DISEASES OP THE SKIN. 

the hair through a cloth saturated with vinegar or dilute 
acetic acid, which will soften the gluey attachment of the 
nits. No attention is to be paid to the dermatitis until after 
the cause of it is removed, when it will rapidly get well 
under any simple treatment. In private practice, an in- 
fusion of staphisagria (larkspur seeds), or a 10 per cent, 
solution of carbolic acid, or a half to one per cent, solution 
of bichloride of mercury, may be substituted for the petro- 
leum. The bichloride should not be used if there is much 
dermatitis. The ointment of the ammoniate of mercury is 
efficient, but, as a rule, an ointment should not be used on 
hairy parts. Blue ointment is a well-known remedy for 
pediculosis pubis, but it is apt to set up a dermatitis that is 
undesirable. 

For pediculosis vestimentorum there is no use in making 
any application to the skin. The w T oollen clothes should be 
baked in a hot oven and the underclothing and sheets should 
be well boiled. If this cannot be done, or new clothes ob- 
tained, powdered sulphur or staphisagria may be powdered 
in all the seams of the clothing. 

Pelade. See Alopecia areata. 

Peliosis Rheumatica. See Purpura. 

Pelioma Typhosum. See Maculae caerulese 

Pellagra (Pe 2 l'-la 3 -gra 3 ). Synonyms : Risipola lombarda ; 
Mai de la rosa ; Mai roxo ; Lombardian leprosy. 

Symptoms. But few cases of this disease have been re- 
ported in this country. Since the number of Italians is 
constantly increasing here it is important for us to be able 
to recognize the disease. It has prodromal symptoms of 
progressive weakness, intestinal catarrh, lassitude, giddiness, 
headache, and burning sensations in back, limbs, hands, and 
feet. These make their appearance in the spring, and 
shortly after an erythema affects the backs of the hands 
down to the articulation of the first and second phalanges, 
the backs of the wrists and forearms up to the elbow, the 
backs of the feet, if the person goes barefoot, the front of 
the neck and chest to the lower edge of the first piece of the 
sternum, and, in women and children, the forehead, nose, 



PELLAGRA. 351 

and cheeks — that is, all those regions exposed to the sun. 
The color is bright, dark, or livid red, and is not a simple 
erythema, as the color cannot be made to completely disap- 
pear under pressure. The skin is often so swollen as to 
prevent all work. Bullae may form upon the affected parts 
and be followed by erosions. In a few weeks desquamation 
begins, but the skin continues discolored and thickened up 
to July or August, when a gradual decline of all the symp- 
toms takes place. During the winter the patient may appear 
quite well, but a relapse is pretty sure to occur daring the 
next spring, and to recur each succeeding spring with ever- 
increasing severity of all the symptoms ; the patient emaci- 
ates, loses strength, develops grave cerebro-spinal neurosis, 
sinks into a typhoid state, and dies. The skin becomes 
atrophied, smooth, shining, cracked, or it may be thickened. 
There is loss of cutaneous sensibility and the erythematous 
redness gradually extends over the whole surface of the 
body. The average duration of the disease is five years. 

Etiology. The disease is endemic in northern and 
central Italy, especially in Lombardy, Venetia, and iEmilia ; 
in the southwestern part of France, and in the north part 
of Spain. It may occur anywhere. Women are most sub- 
ject to it, children least so. It seems to be a disease fos- 
tered by poverty, want, and bad hygiene, and to be induced 
by an almost exclusive diet of decomposed or fermented 
maize or, possibly, other grains. Some cases have been 
traced to the drinking of spirits made from damaged maize. 
It is, therefore, similar in origin to ergotism. It is not 
contagious or hereditary. 

Diagnosis. A suspicion of a case being one of pellagra 
should be aroused whenever an erythema upon the exposed 
parts is met with in a person coming from the regions in 
which the disease is known to be endemic, especially if it 
is combined with more or less lassitude and hebetude. 

Treatment. The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the effi- 
cacy of arsenic for adults, and frictions with chloride of 
sodium solution in children. 



352 DISEASES OF THE SKIN. 

Pemphigus (Pe 2 m / fi 2 -gu 3 s). Synonyms : Pompholyx ; 
(Ger.) Blasenausschlag ; (Ital.) Pemfigo. 

A chronic disease of the skin characterized by the erup- 
tion of successive crops of bullae upon the apparently sound 
skin and with either transient or no antecedent erythema. 

At one time every bullous eruption was a pemphigus, but 
with more careful observation and study a number of bullous 
eruptions have been lifted out of pemphigus, and estab- 
lished as distinct diseases. It is probable that this process 
of elimination will continue. In the meantime a considera- 
ble degree of uncertainty pervades our knowledge of the 
disease, both as to its symptomatology and etiology, and we 
can only stand and await further developments. While in 
this attitude we must have some sort of a chart to guide us, 
and it has been my object to draw its lines with as great 
sharpness as possible. 

The disease is a rare one in this country, only 183 cases 
being reported in a total of 123,746 cases in the statistical 
tables of the American Dermatological Association from 
1878 to 1887. My own experience shows it to be still 
more rare, as I have seen only two cases which I was willing 
to call pemphigus out of some 10,000 cases in public and 
private practice. 

Symptoms. It is usual to describe two varieties of pem- 
phigus, namely : pemphigus vulgaris and pemphigus folia- 
ceus. 

Pemphigus Vulgaris may begin with an outbreak of 
bullae, or there may be more or less constitutional disturb- 
ance before their appearance. The latter condition is more 
often seen in debilitated subjects, children, and old people, 
and consists in chilliness, nausea, and, perhaps, a rise of two 
or three degrees of temperature. These constitutional dis- 
turbances may occur before the appearance of each crop of 
bullae. The characteristic eruption is an outbreak of two 
or more pinhead-sized vesicles that in a few hours develop 
into tense, oval, hemispherical, prominently raised, fully 
distended bullae with translucent contents. The size of the 
bullae varies ; it may be but one-eighth of an inch in diam- 
eter, or, by the coalescence of several neighboring bullae, 



PEMPHIGUS. 353 

large, irregular ones of two or three inches in diameter may 
be formed. One distinguishing feature of these bullae is 
that they have no areola, but spring up at once from the 
seemingly healthy skin. Their contents soon becomes tur- 
bid, or perhaps purulent, and then a slight inflammatory 
halo may form. The bullae do not tend to rupture spontane- 
ously, but to dry up, and leave the dried cover as a crust. If 
they are ruptured accidentally, an excoriated place is left 
that heals more or less readily, according to the general 
condition of the patient. Some pigmentation may be left 
for a time to mark the site of the bullae. 

This eruption may take place anywhere, but affects par- 
ticularly the lower part of the face, the trunk, and limbs. 
It is usually bilateral, and may be roughly symmetrical. 
The life of the individual bulla is two to eight days ; but 
while one crop is disappearing a new one forms, and the 
duration of the disease may thus be measured by weeks or 
months. Sometimes there is an interval of weeks or months 
between the outbreaks. In favorable cases a few crops 
appear, and that is all, the patient making a good and com- 
plete recovery. In less favorable cases, or when the eruption 
is very extensive, frequent relapses and many excoriations 
take place, the patient's strength becomes exhausted by the 
constant drain upon his system and loss of rest on account 
of the discomfort of his condition; he may die in a typhoid 
state, or of some intercurrent affection. A number of cases 
of death from the disease within two or three weeks have 
been reported, and to these the name of acute pemphigus 
is given. A few authorities have reported acute bullous 
eruptions running their course in three to six weeks as acute 
pemphigus. Many of these cases were probably cases of 
bullous erythema, as in many of them a preceding ery- 
thema is noted in the reports of the cases. Most cases run 
a chronic course, extending over months or years. 

In rare instances a diphtheritic membrane may form at the 
site of the bullae, or, instead of healing taking place, a gan- 
grenous process may be set up, with considerable destruc- 
tion of tissue, or hemorrhage may take place in some of the 
bullae. 



354 



DISEASES OF THE SKIN 



Neumann has described as 'pemphigus vegetans a bullous 
eruption in which healing does not take place, but the base 
becomes covered with sprouting granulations and assumes 
an uneven surface marked by furrows and secreting a thin 
fluid. The raw patches thus formed spread slowly at their 
circumference, and neighboring ones coalesce. The disease 
proves progressive ; marasmus, and finally death closes the 
scene. Most of the cases are in syphilitics. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the disease. The conjuntiva is 
not spared, and if attacked serious deformity results. 

'Cases of pemphigus neonatorum have been reported from 
time to time, and epidemics of it have been described. These 
are so evidently septic in origin that they hardly admit of 
being classified under the heading of pemphigus. Careful 
reading of not a few outbreaks of contagious pemphigus 
reported in the German journals will convince one who is 
acquainted with the bullous form of contagious impetigo 
that a mistake in diagnosis had been made by the reporter. 
Still, until further evidence is forthcoming, it is probably 
advisable to allow that both of these varieties of the disease 
do exist. Pempliigus pruriginoxu* is another variety made 
by writers. It fits in quite well under Duhring's dermatitis 
herpetiformis. 

Pemphigus Foliaceus differs considerably from pemphigus 
vulgaris. It may begin as such or it may develop from 
pemphigus vulgaris. Behrend 1 teaches that the difference 
between the two forms is simply a matter of coherence be- 
tween the epidermis and corium, this being so slight in pem- 
phigus foliaceus that we have a flaccid bulla instead of the 
tense, fully distended one of pemphigus vulgaris. 

Pemphigus foliaceus is much the more rare variety of the 
disease, Crocker giving its occurrence as one in five thous- 
and cases. Its characteristic lesions are flaccid bullae, with 
opaque contents, that soon rupture and leave raw, moist 
surfaces with an edge of ragged epithelium. The fluid of the 

1 Vierteljahr. f. Dermat. u. Syph., 1879, vi. 191. 



PEMPHIGUS. 355 

bullae changes its position with the position of the patient, 
always seeking the most dependent part, and soon becomes 
purulent. After the disease has existed some time the 
patient emits a sickening odor on account of the large 
amount of the raw surfaces of the ruptured bullae that are 
bathed with sero-pus. Affecting at first only a limited 
space, by degrees the disease spreads so that the whole body 
surface becomes red and weeping, looking like eczema 
rubrum, with crusts and areas of ragged epithelium. The 
palms and soles are often spared on account of the thickness of 
their epidermal coverings. When the skin is thus generally 
involved it is difficult to establish the fact of the occurrence 
of new bullae. The mucous membranes of the mouth and 
pharynx are affected in like manner, becoming converted 
into raw patches. The hair falls out ; the nails become 
thinner, brittle, atrophied, and, maybe, drop off; and ectro- 
pion is apt to result from contraction of the skin about the 
eyes. The mucous membranes are also attacked, which 
greatly adds to the patient's discomfort. 

The condition of the patient is most deplorable in these 
extensive cases ; his skin is stiff and sore, and perhaps 
smarts ; and after months or years he succumbs to the drain 
on his system, sinks into a typhoid state, and dies. During 
the early part of the disease there may be no constitutional 
disturbance. But eventually death is quite sure to result, 
if not from the disease, from some intercurrent affection 
against which the patient is unable to offer any resistance. 

Etiology. We know very little about the causes of 
pemphigus. The tropho-neurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after 
all, the true one. Experiments have demonstrated that 
bullae can be made to form by operations on the spinal cord, 
and observation has shown that bullae do form in certain 
spinal diseases. Both sexes are equally subject to the dis- 
ease. Children are more often affected than adults. The 
septic origin of certain bullous eruptions has already been 
spoken of under the heading of pemphigus neonatorum. 
Bullous eruptions are hereditary in some families, and in 
some subjects follow slight injuries to the skin. Chilling of 



356 DISEASES OF THE SKIN. 

the body seems to have been the exciting cause of some 
cases. Some have advanced the theory that an excess of 
ammonia in the blood or defective kidney elimination are 
the cause of the disease. Attacks of the disease have been 
observed to occur with each new pregnancy in some women. 
Thus we see that so far we have only more or less ingenious 
hypotheses and theories in answer to our question, What are 
the causes of pemphigus? 

Pathology. " Most authors regard the actual formation 
of the bulla as due to an inflammation of the papillary 
layer, with outpouring of fluid from the vessels, but Aus- 
pitz calls it an akantholysis, or loosening of the prickle-cell 
layer, by the sudden escape of fluid from the vessels, 
destroying the young prickle cells and lifting up the epider- 
mis as a whole. Any inflammatory phenomena, he thinks, 
are secondary "(Crocker). Microorganisms have been found 
in the fluid both of the bullae of chronic and acute pemphi- 
gus, but their connection with the disease has not been 
satisfactorily demonstrated. 

Diagnosis. If we regard the pathognomonic symptoms 
of pemphigus vulgaris as fully distended bulled springing up 
out of the sound skin without any antecedent erythema and 
without inflammatory halo, and occurring in crops so as to 
run a chronic course, then little difficulty will arise in diag- 
nosis. A bullous erythema lias bullae arising upon an ery- 
thematous base or with erythematous lesions elsewhere, and 
runs a comparatively acute course. In bullous urticaria the 
bulla rises upon a wheal. The bullous form of impetigo 
contagiosa will be quite sure to present the characteristic 
impetigo pustules upon the hands or face, and search will 
probably discover some child with impetigo with whom the 
patient has come into contact. Varicella bullosa occurs 
epidemically, and runs a short course. 

Pemphigus foliaceus when in its early stage, and affecting 
but a small area, is readily diagnosticated by the occurrence 
of its flabby bullae, arising without antecedent injury. After 
it has lasted long enough to involve a large area it is with 
difficulty diagnosticated from eczema rubrum and dermatitis 
exfoliativa. In fact without the history of the case it is 



PEMPHIGUS. 357 

sometimes almost impossible to make the diagnosis. It may 
be differentiated from eczema rubrum by its crusts being 
made less of dried exudation than of epithelium, by the 
slighter amount of exudation, by the ragged look of some part 
of the disease, and by careful watching for and finding the 
large flaccid bullae which will be sure to appear if the case is 
one of pemphigus. Moreover, a universal eczema rubrum 
is very rare, and the itching is more pronounced. Derma- 
titis exfoliativa differs from pemphigus in the absence of 
moisture and of bullae, and in the thinness of the exfoliated 
epidermis. Lichen ruber acuminatum is also perfectly dry 
and presents characteristic papules. 

Treatment. The drug upon which most reliance is 
placed in the treatment of this disease is arsenic. We may 
use Fowler's solution ; or arsenions acid in pill form, as the 
tablet triturate with piperina, or the Asiatic pill. Whatever 
form is given it is advisable to begin with small doses and 
push them gradually up until the limit of tolerance is reached, 
or the disease is controlled. Unfortunately it often disap- 
points us in its effects. Attention to diet and hygiene, and 
the general condition of the patient, with the judicious use 
of tonics, such as quinine, iron, and cod-liver oil, will often 
do as much, if not more, than arsenic to cure the patient. 

Locally, dusting powders of oxide of zinc, starch, lycopo- 
dium, or bismuth in varying combinations; lotions of lime- 
water, borax, zinc, liquor plumbi subacetatis, and the like, 
prove helpful in allaying irritation and discomfort. Lassar's 
paste is also a good application. Unna 1 recommends equal 
parts of linseed oil, lime-water, oxide of zinc, and chalk, 
both to dry up the bullae and prevent their return. Lini- 
mentum calcis with one minim of creasote to the ounce is 
recommended by Hardaway. The continuous warm bath 
has afforded great relief in the Vienna hospitals. The 
bullae may be opened if they are troublesome. Alkaline 
and antiseptic mouth-washes will afford relief where the 
mucous membranes are affected. 

Prognosis. The chances of recovery are uncertain. 

1 Monatshefte f. prakt. Dermat., 1888, No. 1. 



358 DISEASES OF THE SKIN. 

While many cases of pemphigus vulgaris recover, relapses 
are the rule, and if the patient is not strong, or the disease 
has lasted a long time, a guarded prognosis should be made. 
Hemorrhagic, diphtheritic or fungating bullae are of bad 
augury. Pemphigus vegetans and pemphigus foliaceus are 
almost invariably fatal. 

Perforating Ulcer of the Foot is an accident liable to 
occur in those in whom the nerve supply to the foot is de- 
ficient, as in locomotor ataxia, syphilis, leprosy, and periph- 
eral neuritis. The most common location for the ulcer 
is at the metatarso-phalangeal articulation of the great or 
little toe, or the cushion of the great toe. It may be only 
on one foot, or both feet may be affected. The process is 
slow, beginning as a proliferation of the epidermis like a corn, 
under which suppuration takes place, and an ulcer is left. 
This goes deeper into the tissues until a sinus forms that 
reaches to the bone. The edges of the ulcer are hard. 
Usually there is little pain, though there may be hyperaes- 
thesia of the surrounding parts. This painlessness distin- 
guishes it from a suppurating corn. The palms may be 
affected in the same way as the soles. The disease is very 
intractable, and must be managed on surgical principles, 
amputation of the whole or part of the foot being required 
in some cases. Death may result from the disease. 

Under the name of " Hand and Foot Disease" Hyde re- 
ports 1 three cases of ulcerations of the hands and feet that 
he regards as due to tropho-neurotic disturbances. In these 
cases, with or without functional disturbances, such as 
hyperidrosis and coldness of the hands and feet, bromidrosis, 
local anaesthesias, vertigo, faintness, and rheumatic pains, 
there were found various grades of dystrophia unguium, 
from roughness to onychogryphosis, tender and painful or 
insensitive maculations of the hands and feet, pigmentary 
patches on the palms and soles or the backs of the hands or 
feet, or both ; different dermatoses, such as erythema, ec- 
zema, ichthyosis, local alopecias, hypertrichosis, symmetrical 
tylosis, with or without spontaneous exfoliation or recur- 

1 Phila. Med. News, 1887, li. 416. 



PERIFOLLICULITIS. 359 

rence. After a time ulcerations formed on the hands or feet, 
or on both hands and feet. 

Periadenitis Sudoripara. See Abscess of sweat glands. 

Perifolliculitis Suppurees et Conglomerees en Placards. 
Under this lengthy title Leloir 1 has described and figured a 
rare disease of the skin which specially affects the backs of 
the hands. 

Symptoms. It seems to commence as a diffused red 
patch upon which develop small pustules, which itch slightly, 
or as small, red, more or less conglomerate, slightly itching 
elevations that form patches. The patches however formed 
are sharply defined, raised from 2 to 5 millimetres, round 
or oval, flattened, and of red, vinous, violaceous, or blue 
color. They vary in size from that of a ten-cent piece to a 
silver dollar, and are often crusted. When the crust is re- 
moved the exposed surface is smooth or mammillated, but 
never papillomatous ; and riddled with a number of pinpoint 
to pinhead-size openings, corresponding to glandular orifices, 
many of which are closed with a plug of greenish, dried pus. 
Besides these openings there are a number of greenish 
points that are ready to become such whenever the epider- 
mis over them is removed. At a more advanced stage the 
openings form small pinhead ulcers. By compression of 
the patch these openings give vent either to a drop of pus 
or serous fluid, or little, elongated, vermicelli-like whitish 
masses. In still more advanced cases the patches become 
more elevated, fluctuation manifests itself, and a sero-pus 
may be expressed. The patches are usually single, but may 
be multiple. The back of the hand and wrist are the usual 
locations of the disease, but it may occur upon the dorsum 
of the foot or the outer side of the thigh, or be disseminated, 
but chiefly located on the extremities. The course of the 
disease is acute. It is fully developed in eight days ; it then 
continues a week or two and disappears in about twelve days 
more. If badly treated, it may last longer, and be followed 
by a papillary condition. It is unattended by subjective 
symptoms, except slight itching. It leaves either no trace 

1 Annal. de Derm, et Syph., 1884, v. 437. 



360 DISEASES OF THE SKIN. 

of itself, or a delicate superficial cicatrix that disappears of 
itself, or a slight staining that soon fades. The hair is un- 
affected, though the disease may involve its follicles. 

Pathology. The disease is a purulent inflammation of 
the skin follicles, specially of the lanugo hairs, and the pilo- 
sebaceous follicles of regions deficient in true hairs. It is 
possibly microbic in origin. 

Diagnosis. The disease is diagnosticated from tricho- 
phytosis barbce by its more rapid course, and recovery under 
simple treatment ; by the hair being unaffected ; and by the 
absence of the trichophyton in the hair. Anthrax differs 
from it in the more pronounced character of its local and 
general reaction, its central core, and inflammatory indura- 
tion Tuberculosis verrucosa cutis is much slower in its 
evolution, is serpiginous, and does not yield to simple treat- 
ment. Eczema differs from it in not having such sharply 
marked borders; in wanting the characteristic openings and 
livid tint; and in having more pronounced itching, a 
mucous, sticky discharge, and a comparatively long duration. 

Treatment. The treatment is simple and consists in 
squeezing out the pus once a day, bathing the part for half 
an hour in warm carbolized water or a solution of boric 
acid, and covering with an antiseptic dressing. If papillae 
have formed they should be scraped off, and the surface 
touched with the nitrate of silver. In some obstinate cases 
it may be necessary to scrape out the whole patch. 

Perionyxis. See Paronychia. 

Perleche (Pe'V-le 2 sh). According to Brocq this is a dis- 
ease occurring in infants and affecting the commissures of 

O CD 

the lips. Their epithelium is pale, macerated, desquamat- 
ing, while the skin underneath is red and slightly inflamed. 
Sometimes fissures will form that are painful, and may 
bleed when the patient widely opens his mouth. The inflam- 
mation may spread to the neighboring regions. It runs a 
course of two or three weeks, but is subject to relapse. It 
is contagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip met 
with in syphilis, but is marked by an absence of all other 
symptoms of syphilis. 



PIEDRA. 361 

The treatment consists in touching the diseased parts with 
the sulphate of copper or alum, or an antiseptic solution, 
and in carefully looking after the nursing bottles. 

Pernio. See Dermatitis calorica. 

Pfundnase. See Rosacea. 

Phagmesis. A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. See Pediculosis. 

Pian. See Yaws. 

Piebald Skin. See Leucoderma. 

Piedra (Pe-ad'ra 3 ). Synonyms : Tinea nodosa ; Tricho- 
mycosis nodosa. 

Symptoms. This disease, or deformity of the hair, is 
said to occur only in Cauca, one of the United States of 
Colombia, and was first described in 1874 by Dr. X. Osorio, 
of the University of Bogota. It consists in the occur- 
rence along the shaft of the hair of from one to ten small, 
dark -colored nodes which are very hard and gritty, and 
rattle like stones when the hair is combed or shaken. The 
stony hardness of the nodes gave the disease its name, 
"Piedra/' which is the Spanish for "stone." These nodes 
are always placed at irregular intervals along the hair-shaft, 
beginning at about half an inch from the point of exit of 
the hair, the root being unaffected. The disease occurs 
most commonly in women, men being rarely affected, and it 
is the head-hair alone which exhibits these nodes. The 
disease is non contagious, and is met with only in warm 
valleys. 

Etiology. Dr. Osorio thought that the nodes were pro- 
duced by an agglomeration of epithelium in certain parts of 
the hair. Dr. Morris 1 believes it is due to the use of a 
peculiar mucilaginous linseed-like oil, which is used particu- 
larly by the native women to keep their hair smooth and 
shiny. Another theory is that it is due to the use of the 
water of certain stagnant rivers which is very mucilaginous. 
Heat seems essential for its production, as the employment 

Lancet, 18 7 9, x. 407. 
16 



362 DISEASES OF THE SKIN. 

of either of these fluids will not cause the disease in cold 
climates. 

Microscopical examination of the affected hair shows 
that the nodes consist of a honey-combed mass of pigmented 
spore-like bodies, the whole mass arising from one cell which 
sends out spore-like columns radially in all directions. As 
soon as the cells have reached a certain size, they seem to 
alter their shape, become darker in color, and form a pseudo- 
epidermis. It is, therefore, a fungous growth. The nodes 
were found to be very hard to cut, and when considerable 
force was used they broke. 

Diagnosis. Piedra differs from trichorrhexis nodosa in 
the stony hardness of the nodes, in its occurring principally 
upon the head-hair, in its probable etiology, and in the 
microscopical appearances it presents. 

By the use of hot water the nodes can be entirely 
removed. 

Pigmentary Mole. See Nsevus pigmentosus. 

Pigmental. See Naevus pigmentosus. 

Pigmentgeschwulst. See Sarcoma. 

Pigmentkrebs. See Sarcoma. 

Pigmentsarcoma. See Sarcoma. 

Pimples. See Acne. 

Pinta (PentV). Synonyms: Mai de los pintos; Tinna; 
Caraate or cute ; Quirica ; Spotted sickness. 

This disease occurs only in southern Mexico, Panama, 
and South America. 

Symptoms. According to Crocker, from whose work 
this account is drawn, it consists of scaly spots varying 
in color, shape, number, and size. They show them- 
selves first on the uncovered parts, but may affect any 
or all of the cutaneous surface. The disease spreads by the 
peripheral extension of old patches and the formation of 
new ones. The patches are round or irregular in shape, 
sharply or ill defined, and of black, gray, blue, red, or dull- 
white color. The red and white patches are deeper-seated 
than the others, being located in the rete and corium. The 
patches may be of uniform color or of different tint, but do 



PITYKIASIS ROSEA. 363 

not change their color after they have once formed. They 
are scaly and usually feel rough and dry. The hair grows 
gray and falls. There is some itching, and a bad odor ema- 
nates from the patient. The course of the disease is chronic 
and shows no tendency to recovery. 

Etiology. The disease is contagious and its spread is 
favored by dirt and neglect. It is most common in the poor 
natives of Indian stock. It is of fungous origin, and, in 
fact, seems to be allied to chromophytosis. 

Treatment. The treatment is the same as for chromo- 
phytosis. 

Pityriasis Capitis. See Seborrhcea sicca. 

Pityriasis Maculata et Circinata. See Pityriasis rosea. 

Pityriasis Pilaris. See Keratosis pilaris. 

Pityriasis Rosea (Pi 2 t-i 2 -ri 2 -a'sis). Synonyms : Pityriasis 
maculata et circinata ; Herpes tonsurans maculosus (Hebra); 
Roseola pityriaca (Barduzzi) ; Pityriasis circine" et margine 
(Vidal) ; Pityriasis rosee (Gibert) ; Erytheme papuleux 
desquamatif. 

An acute disease of the skin characterized by an erup- 
tion of rosy red macules that enlarge into dry, scaly, oval, 
or annular patches with rosy red peripheries and chamois- 
yellow, wrinkled centres ; it runs a definite course and ter- 
minates in recovery. 

Symptoms. Though Gibert described pityriasis rosea 
as early as 1868, the disease is but little known in this 
country, not because it does not occur, but because it is not 
recognized. Still it is one of the rarer skin diseases. Most 
writers tell us that its outbreak is preceded by slight consti- 
tutional disturbances, such as malaise, loss of appetite, and 
headache. These symptoms, in my experience, have been 
as conspicuous by their absence as in the case of impetigo 
contagiosa. The eruption itself most often begins upon the 
upper part of the chest a little above the breasts, or, accord- 
ing to Brocq, 1 at the level of the waist-band, anteriorly and 
a little to one side, where he locates what he calls the 

1 Annal. Derm, et Syph , 1887, viii. 615. 



364 DISEASES OF THE SKIN. 

" primitive patch." The primary lesions are miliary or 
small papules of pale-red color, surrounded by an erythema- 
tous zone. These soon enlarge into rosy red, slightly raised 
macules, and slowly increase peripherally into oval or 
rounded patches with well-defined borders raised somewhat 
higher than the centres. When the patches have attained a 
diameter of half an inch or more the centres begin to clear 
up by becoming of a yellow, old parchment color; scaly and 
shiny, while the border is pale-red. Later the centre may 
disappear and rings only remain, or if two or more patches 
meet at their borders irregular gyrate figures may be formed. 
All the lesions do not attain the same degree of development, 
and in a well-developed case lesions in all stages will be 
found. The lesions are slightly scaly from the commence- 
ment, and the furfuraceous desquamation continues until 
the faint mark left by the lesion disappears. Itching, 
usually slight in amount and only when the person is warm, 
is the only subjective symptom. Sometimes it is severe. 
The eruption is most marked upon the neck, infra- and supra- 
clavicular regions, sides of the chest, and shoulders ; it may 
be marked also on the abdomen and buttocks. The whole 
body may be involved, but the hands and feet are usually 
spared, and it is uncommon on the face. After some three 
to six weeks the disease tends to spontaneous recovery, al- 
though it may last for two months. 

Etiology. We know nothing about the causes of the 
disease. It affects all ages and both sexes. Crocker thinks 
that it is most common in children, but most all the cases 
I have seen have been in young adults. This difference 
may be accounted for by the fact that he has a large chil- 
dren's dispensary service. The disease seems to occur 
epidemically in some instances, and cases are apt to present 
themselves in groups. Contagion has not been established. 
Bazin regards it as arthritic. It may be parasitic, but as 
yet the parasite awaits discovery. Vidal 1 describes a para- 
site that he names the microsporon anomceon, as found 
in pityriasis circine* et margine, a disease probably the same 
as pityriasis rosea. 

1 Annal. Derm, et Syph., 1882, iii. 22. 



PITYRIASIS RUBRA PILARIS. 365 

Diagnosis. Pityriasis rosea must be differentiated from 
the early circinate, scaling, macular syphiloderm ; annular 
psoriasis ; seborrhcea sicca corporis ; and disseminated tri- 
chophytosis. The one most distinguishing feature of pity- 
riasis rosea is the wrinkled old-parchment yellow of the 
centre of the ring. This is absent from the lesions of all 
the other diseases with which it is likely to be confounded. 
The syphilide is of a less bright-red color, and there surely 
will be some other evidence of syphilis to guide us. Psori- 
asis is far more scaly ; the scales are of a white color ; the 
tips of the elbows and the anterior face of the knees will be 
specially affected; and typical psoriatic patches will be found 
somewhere. Seborrhcea corporis occurs upon the middle 
sternal and inter-scapular regions particularly : the patches 
have a greasy feel ; the scales are thicker than in pityriasis 
rosea ; and the lesions show little tendency to spontaneous 
involution. In trichopliytosis the fungus is readily found 
under the microscope, which is a decisive test. Apart from 
that, ringworm does not spread so rapidly, nor involve such 
wide areas. 

Treatment. Pityriasis rosea is a self-limited disease, 
and recovery is sure to take place in a short space of time. 
My experience has been that the only reason for treating 
the disease is to amuse the patient, and that nothing has 
any marked effect on it. The use of salicylic acid in vase- 
line, ten to twenty grains to the ounce is as good as any- 
thing. We can use boric acid or mild sulphur ointment, 
or content ourselves by allaying the itching with lotions of 
carbolic acid (ten grains to the ounce), calamine, oxide of 
zinc, and the like. 

Pityriasis Rubra. See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. This disease has recently been 
described bv the French writers. The following account is 
abstracted from an admirable paper by Besnier. 1 

It has been confused with lichen pilaris, psoriasis, lichen 
ruber acuminatus et planus, and pityriasis rubra. Several 
cases of lichen ruber reported in this country have been 

1 Annul. Derm, et Syph., 1889, x. 253, et seq. 



366 DISEASES OF THE SKIN. 

declared by the French to be cases of the disease under con- 
sideration, as well as the lichen psoriasis of Hutchinson. 

Symptoms. A typical case has three principal elements : 
1. Asperities of the follicular orifices; 2. Desquamation; 
3. Roughness of the skin with exaggeration of its folds. 
The disease generally begins suddenly, without prodroma, 
but there may be some malaise, nervousness, insomnia, 
hyperesthesia of the finger-ends, formication, and the like. 
These prodromata are of short duration, and rarely cause 
the patient to go to bed. The uncovered parts are usually 
first affected with the eruption, but it may appear primarily 
upon the trunk or extremities. The initial lesion may be a 
simple exfoliation ; an erythema ; a scaling erythema ; a 
fine but scanty furfuraceous desquamation ; a shiny redness 
with pityriasis; desquamation of nail-bed, or fragility of 
nail. However beginning, the more pronounced form 
appears in a certain number of days or weeks, and may 
develop or abort at any point, or be limited to any region, 
or involve the whole body. When fully developed a patch 
or the w T hole skin, as the case may be, presents the following 
characteristics : It is covered with elevations that are gen- 
erally conical, but may present great diversity of shape. 
These may be discrete or coalesce. They may be so small 
as to be seen only by the aid of a microscope, or elevated 
many millimetres above the surface, with corresponding 
diameter. They are scaly, and vary in color from a 
silver-white or gray, to a bright or opaque red, red-brown, 
or rosy yellow. Their summits may be flat, uneven, cone- 
shape, or truncated, giving issue to a hair broken off 
at a little distance above the surface of the skin, and may 
be sheathed by a corneous or sebaceo-squamous case. In- 
stead of a hair protruding, it may form only a small comedo- 
like spot at the centre of the summit, or it may be wanting, 
or it may seem to exist alone, giving to the region the appear- 
ance of a badly shaven beard. Sometimes the cone pre- 
sents a crater, at the bottom of which is a black point, a 
punctured scaly plate, or a psoriatic point. When sev- 
eral elevations coalesce their borders disappear and form a 
squamous patch, showing the central points and the asso- 



PITYRIASIS RUBRA PILARIS 367 

ciated piliary cones. The skin is scaly, dry, hard, rough 
like a file, and presents a " goose-skin" appearance. The 
scales may be scraped off without any loss of blood. The 
disease is generally symmetrical, but the lesions may be dis- 
seminated without order, or in irregular lines, groups or 
islands, or may unite in tessellated areas. The cone-like 
elevations do not occur on the scalp and are rare on the 
soles and palms. In these locations the disease takes the 
form of abundant desquamation upon a reddened base. All 
other regions may be affected, the cones forming about the 
follicles of the skin, especially about the hair follicles. 
Some variations from the type are encountered in different 
regions, but characteristic types will be found somewhere on 
the body. The hair may fall, and the nails may be de- 
formed, opaque, and raised by an accumulation of scales 
under them. 

The general condition is unaltered, and little, if any, dis- 
comfort is experienced. The duration of the disease is 
indefinite, and relapses are the rule. Second and subse- 
quent attacks may be shorter than the first. 

Etiology. The etiology of the disease is obscure. It 
occurs at all ages, and in both sexes, but most often in 
infancy or youth, and in males. Many causes have been 
assigned to it, such as cold, excesses, rheumatism ; but none 
of these can be definitely said to be the cause. 

Diagnosis. The disease is to be diagnosed from ichthy- 
osis in not being congenital; in attacking by preference 
the joints, scalp, face, and neck ; and in its spontaneous 
recovery for a time. From dermatitis exfoliativa by its 
benign course; its location about the follicular openings ; 
and by the thick scaling of the palms and soles. From 
lichen ruber acuminatum the diagnosis is difficult, the two 
being considered by many as identical Hebra (Jr.) has 
made a careful study of the two diseases, 1 and we give here 
his table of differential diagnosis between them. 

1 Monatshefte f. prakt. Permat., 1889, x. 101. 



368 



DISEASES OF THE SKIN. 



Pityriasis Eubra Pilaris. 

1. Develops in the epidermis. 

2. Efflorescences bear scales from 

the beginning, and often con- 
sist of accumulations of epi- 
dermic scales alone which 
can readily be scratched off. 

3. Efflorescences limited to folli- 

cle mouths, especially those 
of hair follicles. 

4. Extensor surfaces of the ex 

tremities especially affected. 

5. Microscopically consist of 

thickening of the epidermis, 
with lengtheningof the inter- 
papillary projections of the 
rete mucosum in certain 
places. 

6. Color of efflorescences scarcely 

differs from that of the skin 
at the beginning. After- 
ward becomes rosy or brown- 
ish-red from consecutive hy- 
peremia. 

7. Eoughness of the extensor sur- 

faces of the extremities, and 
satin-like smoothness on the 
trunk, with fine scales. 

8. No accompanying subjective 

symptoms. 



9. No implication of the general 
health. 



10. Spontaneous recovery, or 

chronicity without danger to 
the patient. 

11. Cured by purely local means, 

though often obstinate. 



12. Little or no pigmentation left. 



18. Does not affect the mucous 
membranes. 



Licben Ruber Acuminatus. 

1. Develops in the cutis. 

2. From the beginning they are 

smooth and glistening. Scales 
form only late in the disease. 



3. Are not limited to the follicle 

mouths. 

4. Flexor surfaces more affected 

than extensor surfaces. 

5. Marked collections of round 

cells in the papillary layers 
of the corium. 



From beginning a bright red, 
becoming darker, and may 
change to deep rusty-brown. 



7. Everywhere thickening and 

roughness of the skin, in- 
creasing with the age of the 
disease. 

8. Unbearable itching, great 

burning, restlessness, and 
jerking movements of the 
limbs. 

9. Fever, oedema (especially of 

lower extremities), albumin- 
uria, sleeplessness, general 
prostration, and loss of 
weight. 

10. Often ends in death, always 

attended with marasmus. 

11. Cured, if at all, by constitu- 

tional treatment, as with 
arsenic. Unna's ointment 
of mercury and carbolic acid 
good. 

12. Deep-brown, even blackish- 

brown, pigmentation left 
which may last for months. 
13. Affects mucous membranes, 
especially of mouth and 
vagina. 



Psoriasis at times bears a strong resemblance to pityriasis 
rubra pilaris, but it seeks the elbows and knees particularly ; 



POLYTRICHIA. 369 

its scale is larger ; and it is not a follicular disease, never 
presenting comedo-like plugs, broken-off hairs, or little 
elevations. 

Treatment. No satisfactory treatment has been found, 
but the remedies applicable to psoriasis or to ichthyosis can 
be used with advantage. Like in that disease, an attack may 
be overcome, but no assurance can be given against a relapse. 
Thus far no fatal case has been reported. 

Pityriasis Versicolor. See Chromophytosis. 

Plaques des Fumeurs. See Leucoplakia. 

Plica Polonica (Pli'ka 3 Pol-oV^-ka 3 ). Synonyms : Tri- 
chosis plica ; Trichoma ; (Pol.) Koltun ; (Grer.) Weichsel- 
zopf; (Fr.) Plique polonaise; Polish ringworm. 

Symptoms. This is rather a condition than a disease, in 
which the hair of the head and other parts becomes matted 
together into various shaped masses, on which rest all sorts 
of extraneous matters deposited from the air ; and in which 
are harbored vast hordes of pediculi. Sometimes these 
matted tresses are near the scalp, and sometimes far away, 
according to circumstances, such as the growth of the hair 
and disease of the scalp. Not infrequently an oozing eczema 
of the scalp will be found. The masses will assume all 
sorts of shapes to which various names have been applied. 
An offensive odor often emanates from the scalp. Occur- 
ring among ignorant people, as is usually the case, these 
plicas are regarded with superstition. The patient and 
friends refuse to have them cut off lest some dire disease 
befall the bearer. 

Etiology. The cause of the condition is want of clean- 
liness combined with an oozing dermatitis of the scalp due 
to pediculi or any other cause. 

Treatment. The treatment consists in the liberal use 
of soap and water, and curing the dermatitis. If allowed, the 
speediest way of beginning treatment is to cut off the hair. 
The patient must be instructed in the hygiene of the scalp. 

Podelcoma. See Fungous foot of India. 
Poils Accidentels. See Hypertrichosis. 

Polytrichia. See Hypertrichosis. 

16* 



370 DISEASES OF THE SKIN. 

Polypapilloma Tropicum. See Yaws. 
Porpora Emorrhagica. See Purpura. 
Poliotes. See Canities. 
Polyidrosis. See Hyperidrosis. 

Pompholyx (Po 2 m / fo 2 l-i 2 x). Synonyms ; Dysidrosis ; 
Cheiro-pompholyx. 

This disease was first described by Tilbury Fox and 
Jonathan Hutchinson from the same case, though independ- 
ently of each other. The former thought that it was due to 
distention of the sweat glands, and named it dysidrosis, 
while the latter named it cheiro-pompholyx from the bullous 
character of the eruption, and its occurrence upon the 
hands. As it occurs upon the feet as well as the hands, 
Hutchinson's name is a misnomer. 

Symptoms. The first thing that the patient notices is a 
burning and itching of the palms, or soles, and sides of the 
fingers or toes. Jn a few hours small, clear, sago-grain- 
like vesicles, sometimes grouped, and with an erythematous 
zone about them, appear in these locations. They are often 
very numerous, and some of them run together to form 
small and large bullae. Their contents are at first neutral ; 
later they become turbid and have an alkaline reaction. 
These vesicles do not tend to spontaneous rupture. In a 
few days they dry up, their covers fall, and large and small, 
dry, red surfaces are left to mark their location. If the 
lesions have been verv numerous the whole of the old skin 
may be shed. In slight cases the palms or soles will be 
dotted over with irregularly shaped red spots with ragged 
edges. As a rule the backs of the hands and feet are 
unaffected, though the rule has rare exceptions. The face 
may be the site of a similar eruption, and be covered with 
firm small sago-grain-like vesicles. The patients are seldom 
in perfect health, but are usually nervously depressed. 
Hyperidrosis of the affected parts commonly accompanies 
or precedes the outbreak, and sometimes a lichen tropicus 
will be found on the trunk. The duration of the attack 
varies from a few days to three or four weeks, and relapses 
in the same or following years are common. On the face 



POMPHOLYX. 371 

the disease has no definite course, but lasts for months or 
during the continued action of the cause. Most all cases 
are seen in the summer. It is usually symmetrical, though 
one side may be affected before the other. 

Etiology. Over the causes of the disease there has been 
and still is active discussion. It seems to be in some way 
connected with the sweat glands, but whether it is a simple 
impediment to the escape of the sweat, or an inflammatory 
disease is not determined. Some able pathologists ally the 
disease to herpes. As it affects the face it is certainly a 
disease of the sweat apparatus, since it occurs in most cases 
in washerwomen who are exposed constantly to heat and 
moisture. The occurrence of the disease in hot weather 
also points to the sweat apparatus as the organ at fault. 
There is probably a vasomotor neurosis at the bottom of 
the trouble. It affects all ages and both sexes, though most 
common in young adult women, and in those who are of 
nervous temperament. 

Diagnosis. Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum. It 
differs from eczema in its vesicles not tending to break 
down of themselves ; in not presenting a moist surface after 
the vesicle-tops fall ; and in running a more definite course. 
The sago-grain-like appearance of the vesicles is not pecu- 
liar to it, as it is frequently seen in eczema of the hands, 
and is due to the thickness of the epithelium preventing the 
ready escape of the fluid. Scabies may bear a close resem- 
blance to pompholyx, but can be readily differentiated by 
finding the burrows, and by the presence of the eruption at 
the same time upon the anterior face of the wrists, the breasts 
in women, the genitals in males, and about the umbilicus in 
both sexes. Pemphigus of the hands and feet is exceed- 
ingly rare in adults, and pompholyx has never been reported 
in infants. Moreover, pemphigus lacks the vesicular lesions 
of the sides of the fingers. Erythema bullosum is always on 
the backs of the hands, and is not itchy though it may 
burn. 

Treatment. A simple astringent ointment, as of oxide 
of zinc, or diachylon ; or one of the oleate of zinc or lead ; 



372 DISEASES OF THE SKIN. 

or an alkaline lotion, will allay the irritation and hasten the 
disappearance of the disease. General hygiene should be 
enforced; and tonics of iron, arsenic, or whatever seems 
indicated by the condition of the patient, given. 

Porcellanfriessel. See Urticaria. 

Porcupine Disease. See Ichthyosis. 

Porrigo Contagiosa. See Impetigo contagiosa. 

Porrigo Decalvans. See Alopecia areata. 

Porrigo Favosa. See Favus. 

Porrigo Furfurans. See Trichophytosis capitis. 

Porrigo Granule. See Pediculosis. 

Porrigo Larvalis. See Impetigo 

Porrigo Lupinosa. See Favus. 

Post-mortem "Warts. See Tuberculosis verrucosa cutis. 

Prairie Itch. This disease has been found to be in most 
cases a combination of pruritus hiemalis and scabies. It 
is not a disease sui generis. 

Prickly Heat. See Miliaria. 

Prurigo (Pru-ri'go). Synonyms : Strophulus prurigi- 
neux ; Scrofulide boutonneuse benigne ; (Ger.) Juckblat- 
tern. 

A chronic disease of the skin characterized by beginning 
in infancy as an urticaria, and changing into a recurring 
eruption of pale, hard, exceedingly itchy, discrete papules, 
especially upon the extensor surfaces of the extremities. It 
increases in severity from above downward, and is accom- 
panied by enlargement of the inguinal glands. 

There are two types of this disease, namely : prurigo 
mitis and prurigo ferox. These two blend into each other. 
While the malady is more commonly reported from Vienna 
than elsewhere, it occurs in many countries. Until very 
recently it was regarded as very rare in this country, but as 
Zeisler, 1 of Chicago, has met with twelve cases during five 
years, and among 1370 skin cases, it is not so rare a disease 
in that section. American physicians have hesitated in 

1 Journ Cutan. and Gen.-urin. Dis , 1880, vii. 408. 



PRURIGO. 373 

making the diagnosis of prurigo because they had in mind 
rather prurigo ferox than prurigo mitis, as a type; and be- 
cause of its resemblance, in many instances, toother diseases. 
The name is used by most French writers as synonomous 
with pruritus, and English writers quite commonly speak 
of " pruriginous " diseases when confusion would be avoided 
by using the adjective " pruritic." 

Symptoms. The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak of 
urticarial wheals of various sizes and shapes. The urtica- 
rial eruption persists, but after a time a preponderance of 
small wheals will be remarked, and a preference for the 
trunk and the extensor surfaces of the limbs. During the 
second or third year the urticarial element is lost and the 
characteristic papular eruption gradually preponderates, and 
at last takes its place. The papules are pinhead to hemp- 
seed in size, flat, firm, of the color of the skin, or of a 
bright-red, rosy, or yellowish-white color, and in many 
cases so little raised as to be felt rather than seen. When 
the skin is irritated the papules may assume the character 
of small wheals. The efflorescence is located principally 
upon the extensor surfaces of the limbs, and more sparsely 
on the trunk, while the scalp, the flexures of the large 
joints, the palms, soles, and genitals are free. The papules 
are not grouped. 

Pruritus is intense, so that excoriations and torn papules 
are present over all the affected parts. The patients have a 
pale, weary expression of countenance, and evidently are in 
poor condition. The skin is often dry and may be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities, we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shown in the Vienna 
skin clinics. We note that the skin feels rough ; that it is 
strewn over with a great number of small papules which are 
of the color of the skin or pale-red ; defaced with scratch- 
marks ; eczematous in places ; darkly pigmented, it may be 
brown, from constant irritation of the scratching, and that 



374 DISEASES OF THE SKIN. 

this color of the general integument is in strong contrast 
with the pale color of the face ; that the skin is thickened 
in some places while the flexures of the joints are free from 
change and as soft as normal ; that these changes in the 
skin are progressively worse from above downward, so that 
the legs from the knee down are most markedly involved ; 
and that the inguinal glands are enlarged so as to form 
buboes. Ecthymatous lesions may arise. The intensity of 
the itching may be so great as to prevent sleep, and even 
in some cases to drive the patient insane. 

The duration of the disease is indefinite ; it may last a 
lifetime. The type of the disease remains the same through- 
out — that is, prurigo mitis does not change to a prurigo ferox. 

Etiology. Prurigo affects both sexes, though more prev- 
alent in the male sex. It is far more common among the 
poor and those who are uncleanly. It is not uncommon to 
find several members of the same family with the disease. 
A phthisical family history has been affirmed to be an etio- 
logical factor by some authorities. Some cases are better in 
winter and some in summer. It is a disease of infancy con- 
tinuing through life. A neurosis probably is the underly- 
ing cause of the phenomena, and it seems to be related to 
urticaria. Histological studies have not yet put the disease 
upon a sure anatomical basis. 

Diagnosis. The diagnosis is made by the occurrence of 
pale papules upon the extensor aspects of the limbs ; by the 
increasing severity of the symptoms from above down- 
ward; by the enlargement of the inguinal glands, and by 
the continuance of the disease from early infancy. It is to 
be differentiated from eczema by sparing the flexures of the 
joints ; by the presence of its characteristic papules, and by 
its greater obstinacy. From papular urticaria it can be 
distinguished only by its general course. In fact, a doubt- 
ful case must be carefully studied over a considerable length 
of time before a positive diagnosis can be made. Scabies 
and pediculosis can be readily separated by the occurrence 
of the lesions on the palms, between the fingers, and on the 
genitals in the one ; and the parallel scratch-marks over the 
shoulders in the other. Ichthyosis spares the flexures as does 



PRURIGO. 375 

prurigo, but it is marked by polygonal scales, not papules ; 
and is free from the great number of excoriations found in 
prurigo ; it is, moreover, a disease that affects the whole 
body surface more generally. 

Treatment. The disease is exceedingly obstinate to 
treatment. The patient must be put in as good a physical 
condition as possible by means of hygiene, cod-liver oil, iron, 
and good diet. Tincture of cannabis indica is commended 
by Crocker for relief of the itching in doses of ten minims 
increased to thirty minims to a ten-year-old child, given 
three times a day directly after meals, and intermitted for 
two weeks after every six weeks. Simon 1 and others rec- 
ommend pilocarpine hypodermatic-ally, fifteen minims of a 
2 per cent, solution once a day, for adults, or a correspond- 
ing quantity of jaborandi by the mouth. After the dose the 
patient is to be put in bed and covered with woollen blankets, 
where he is allowed to sweat for two or three hours. Carbolic 
acid, fifteen to twenty grains a day in pill, and the bromide 
of potassium, have their advocates. Antipyrine and phena- 
cetine exert a controlling influence over pruritus, and they 
are amongst the most valuable internal remedies in prurigo. 
The latter, though not so active as the former, should be 
tried first in full doses, as it is much safer. 

External treatment is very important. Naphthol is 
most highly commended, a 2 to 5 per cent, solution, accord- 
ing to age, being rubbed in every night, and a bath of 
naphthol-sulphur soap being taken every second night. In 
older children and adults the soap treatment of Hebra, as 
described in the section on Eczema, is useful. Sulphur oint- 
ment used as in scabies after a daily bath ; tar used as in 
psoriasis ; a 5 or 10 per cent, lotion of carbolic or salicylic 
acid, or the same combined with vaseline ; a 5 per cent, 
boric acid ointment, all have their advocates, and all may 
be tried in obstinate cases. Baths followed by inunctions 
of cod-liver oil, simple oil, tar oil, or lard, are often useful ; 
as well as baths of alum, soda, and corrosive sublimate. 
Treatment should be continued for weeks or months after 
apparent cure of the disease. 

1 Berlin, klin. Wochenschr., 1879, xvi. 721. 



376 DISEASES OF THE SKIN. 

The prognosis as to cure is bad, excepting in recent and 
not severe cases. These may be cured, but, as a rule, all 
we can do is to mitigate the patient's discomfort. Relapses 
are the rule. 

Pruritus Cutaneus (Pru-ri'-tu 3 s). Itching of the skin is 
a symptom common to a great variety of dermatoses. In- 
deed, it has been said that skin diseases might be classified 
under two divisions: those that itch and those that don't 
itch. Eczema, scabies, urticaria, prurigo, pediculosis, are 
all eminently pruritic, but do not concern us here. 

Symptoms. By pruritus cutaneus we mean a functional 
neurosis of the skin whose only essential symptom is itch- 
ing. This induces scratching, and scratch-marks are always 
to be found as a secondary symptom. These usually are in 
the form of scratched papules. If the itching is great and 
continuous, we will have other secondary effects, such as 
thickening and pigmentation of the skin, and eczema of 
various degrees. 

The itching varies greatly in degree from simply an 
occasional slight attack to such an intense degree as to 
render the patient's life unendurable and tempt to suicide. 
The pruritus is commonly paroxysmal, but in some cases 
the pauses between the paroxysms are so short that the itch- 
ing is practically continuous. It is almost always worse at 
night. Changes of temperature aggravate the itching, as 
a rule. Very commonly warmth makes matters worse, and 
the sufferer will begin to scratch and keep on scratching 
while in the neighborhood of a fire, or in bed warmly 
covered. He cannot resist the impulse to scratch, and so 
in bad cases he shuns society and becomes morbid. 

Under the general title of pruritus are often placed 
various paresthesia, such as formication, tingling, and 
burning. 

The pruritus may be general or local. Thus we have 
pruritus universalis, a term that is rarely to be applied 
with strict accuracy, as it is seldom universal, and only 
general. In these cases the itching is now one place and now 
another. Bulkley, 1 by a series of observations on himself, 

1 Journ. Cutan. and Gen.-urin. Dis., 1887, v. 15'.'. 



PRURITUS CUTANEUS. 377 

strove to establish some law of reflex excitation, in which 
he was so far successful as to find that if he scratched one 
spot that itched, he relieved the sensation there, only to have 
it break out elsewhere. This general pruritus is most often 
encountered in pruritus senilis, or the itching of the skin 
of old people, and in pruritus hiemalis and pruritus cesti- 
valis which are induced respectively by the cold of winter 
or the heat of summer. These very often manifest them- 
selves on the thighs and legs only. 

Of local pruritus we have many instances. Thus we 
have pruritus ani which afflicts both sexes and in which the 
itching extends to the mucous membrane of the anus. 
This same extension is also seen in pruritus vulvae. This 
localized itching, with the corresponding pruritus scroti in 
men, often occurs in connection with pruritus ani. In all 
these three the parts almost always become thickened and 
eczematous from the constant rubbing and scratching; to 
which they are subjected, and nymphomania is sometimes a 
consequence of the itching vulva. The scalp, face, espe- 
cially about the nose and mouth ; the palms and soles, and 
between the fingers and toes, are frequent sites of itching. 
More rarely local areas anywhere will be affected with 
recurring attacks of itching. 

Etiology. That the pruritus is due to a functional dis- 
turbance of the sensory nerves there is no doubt. For suc- 
cess in treatment and accuracy in prognosis it is necessary 
for us to endeavor to determine the cause of such disturb- 
ance. Hepatic derangements cause a certain proportion of 
cases. The intense itching of the skin in jaundice is evi- 
dence of this. Digestive disorders and constipation ; excre- 
tory disorders, as of the kidneys and skin; albuminuria; 
lithremia ; and diabetes, all have influence in causing pruri- 
tus. Depressed mental states, and the disorders of the ner- 
vous system induced by the abuse of tobacco, tea, alcohol, 
opium, and the like, produce pruritus. Reflex influences 
from the sexual sphere, and the power of imagination, are 
responsible for some cases. In illustration of the latter 
everyone knows how many people will begin to scratch 
when the subject of lice is mentioned; and how that long 



378 DISEASES OF THE SKIN. 

after the acarus is killed in scabies the patient will continue 
to complain of itching, and will not be assured that he is 
cured of his disease. 

In pruritus senilis the skin will be found to be atrophied 
and the fatty tissue underlying it absorbed, in not a few 
cases. Pruritus ani is often due to hemorrhoids or fissures 
of the mucous membrane ; or to ascarides ; or to the exces- 
sive use of tobacco. Stricture of the urethra has been found 
to be the cause of both it and pruritus scroti. Pruritus 
vulvse is very often due to pregnancy or tumors of the 
uterus or ovaries. In this form diabetes is quite com- 
monly the cause. Pruritus hiemalis begins at any time 
from October to January, and continues until the spring is 
well advanced. The effect of cold upon the skin seems to 
check the secretory functions. 

Bulkley has found pruritus to be more common in men 
than women, fifty of his eighty cases being men. In some 
families an itching skin seems to be hereditary. 

Diagnosis. If we bear in mind that pruritus has no 
lesion of its own ; and if, whenever a patient complains of 
itching of the skin, we institute a search for the pediculus, 
or the itch-mite, or their lesions ; or the wheal, or at least a 
history of it ; and find none, then we have gone far towards 
establishing a diagnosis of pruritus. Sometimes it is diffi- 
cult to determine whether an eczema is secondary to the 
scratching for the relief of itching, or the itching is a part 
of the eczema. Only an attempt at curing the eczema and 
long observation of the case will enable us to make a true 
diagnosis. Many errors of diagnosis will be changed by 
close study, as true pruritus is not so common as other itch- 
ing diseases. Bulkley found but eighty cases in 5000 pri- 
vate cases. 

Treatment. To find and remove the cause is the first 
essential in treating a case. How difficult this task may be 
will be seen by a study of its etiology. Nevertheless the 
patient must be considered, and every organ interrogated, 
and any deranged function regulated as far as possible. 
Tea, coffee, and tobacco should be interdicted; a dietary 
carefully laid down ; and the rules of hygiene, such as those 



PRURITUS CUTANEUS. 



379 



relating to exercise, bathing, and clothing, enforced. To 
relieve the itching as such, we may give the tincture of 
cannabis indica, 10 minims three times a day, in water after 
meals, and gradually increase the dose up to 20 or 30 minims ; 
or the tincture of gelsemium in 10-minim doses every 
half-hour till one drachm is taken or toxic effects produced ; 
hypodermatic injections of pilocarpine, ^ to ^ of a grain ; 
quinine, 10 to 15 grains at bedtime; carbolic acid, 1 to 2 
minims three times a day ; wine of antimony, 5 to 7 drops 
after meals ; salicylate of soda, 15 grains, or antipyrin or 
phenacetine in full doses. Besnier recommends valerian, 
or valerianate of ammonia. But the relief so obtained is 
transitory, and we should not rest content until we have 
found out, and where possible removed, the internal under- 
lying cause. Opium should never be given, as it causes 
pruritus. 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 
purpose general baths with soda (5viij-x to 30 gallons), or 
nitric or hydrochloric acid (§j to 30 gallons), may be used. 
After the bath, the body is to be dried by wrapping in 
a warmed sheet and patting the skin dry ; then the skin 
should be smeared with vaseline and powdered with corn 
starch from a dredger. For local pruritus we may use 
lotions, of which one of the most efficient is carbolic acid : 
5j-ij in alcohol dil. Sj- The patient should be cautioned 
to tap the skin gently with this, and not rub it in. So used 
it will cause no damage and will stop the itching for hours. 
It may be used as a spray in the strength of half an ounce 
to the pint of water with one ounce of glycerin. To this 
5 to 10 minims of oil of peppermint may be added (Hard- 
away). Alkaline lotions, as bicarbonate of soda, 5j to the 
basinful of water ; or acid lotions, such as vinegar dabbed on 
the itching spot, will often relieve. Liquor carbonis deter- 
gens, 5i to §iv : thymol, 5ij, liquor potassii, 5j» glycerin, 
5iij, aquae, Sviij (Crocker). Liquor picis alkalinus, 3j to 
oiv : perchloride of mercury, gr. J-3 to 5J of water. All these 
are well attested as useful. 

For pruritus ani, scroti, et vulvae, sitting over a basin 



380 DISEASES OF THE SKIN. 

or pail of very hot water and sopping it up on the parts, 
followed by patting the skin dry and using a starch powder, 
will often give the patient a quiet night. If an eczema is 
present, that must first be cured. Cocaine lotions, as one of 
20 per cent of cocaine and 5 per cent, of glycerin ; or men- 
thol 3 to 10 percent, in oil of sweet almonds, or of glycerin, 
and water; carbolic acid lotions, are also useful, as well as 
many mercurial ointments. Bulkley's antipruritic powder, of 
one drachm each of camphor and chloral, rubbed together 
till liquefied, and added to one ounce of starch powder, will 
sometimes prove very effective. Painting the parts with 
nitrate of silver, 16 grains in spts. setheris nitrosi, 5j j is another 
good proceeding. A saturated solution of boric acid is also 
good. When the parts are excoriated neither menthol, pep- 
permint, nor the chloral-camphor powder can be used. Sup- 
positories containing belladonna, cocaine, or creasote may 
give relief in these cases. 

In pruritus hiemalis it is sometimes necessary for the 
patient to wear linen underclothing next to the skin ; and 
over these the woollens usually worn. Other patients find 
more relief from wearing silk underclothing. The treatment 
indicated above for pruritus is applicable here also. 

In some obstinate cases of general pruritus great amelio- 
ration may be obtained by the actual or Paquelin cautery 
applied lightly along the spine. The same means has some- 
times been successful in localized pruritus, as of the vulva 
or scrotum, but now the parts themselves are touched with 
the cautery. 

Prognosis. The prognosis is doubtful. Some cases are 
very obstinate, and some are incurable. Happily, thorough 
study of the case will be rewarded in most cases by a cure. 

Pruritus Hiemalis. See Pruritus cutaneus. 

Pseudo Exantheme Erythemato-desquamatif. See Pity- 
riasis rosea. 

Pseudo Erysipelas. By this term is meant cellulitis or 
diffused phlegmon. 

Pseudo Leucaemia Cutis is a very rare disease. A case is 



PSORIASIS. 381 

reported by Joseph 1 as occurring in a man of previous good 
health. It commenced as a number of small glandular 
swellings in the neck. Shortly after their appearance 
severe general pruritus began to afflict the patient. Then 
the inguinal and axillary glands became greatly enlarged, 
and a general eruption of hempseed-sized papules occurred. 
These were more easily felt than seen, and were of pale- 
red color. The epidermis over them was unchanged. 
Wheals also appeared that changed into papules. The skin 
between the papules was dark-colored, thickened, and dry. 
The case ran a chronic course, marked by relapses. 

Psora. See Psoriasis. 

Psoriasis (So-ri 2 -a'-si 2 s). Synonyms : Lepra ; Lepra 
alphos ; Alphos ; Psora ; (Ger.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or oval, bright-red patches covered with more or less 
thick, silvery white, adherent scales ; by occurring especially 
upon the extensor surfaces of the elbows, knees, and extremi- 
ties, and upon the scalp ; by running a chronic course 
marked by remissions and relapses ; and by being more or 
less pruritic. 

This is one of the more common skin diseases, forming in 
this country about 3 per cent, of all cases. 

Symptoms. Its features of variously sized, sharply de- 
fined red patches covered with more or less abundant sil- 
very white scales that occur specially upon the extensor 
surfaces of the elbows and knees, are so pronounced that the 
disease once seen is readily recognized even by the tyro. 

The primary lesion of psoriasis is always a rather bright- 
red, pinhead-sized papule covered with a dry silvery white 
or grayish scale. It is rare to meet with a case in which 
these small lesions are seen alone, and when it is, it is called 
psoriasis punctata. Careful search of any but an inveterate 
case will be rewarded by finding these lesions somewhere on 
the body. They soon begin to enlarge by peripheral exten- 
sion into larger patches which have received various names, 

1 Deutsche med. Wochenschrift, 1889, p. 946. 



382 DISEASES OF THE SKIN. 

although all the same disease. When they attain the 
diameter of about one-quarter of an inch and bear a rather 
thick scale, they look like drops of mortar, and the case is 
then spoken of as psoriasis guttata. When the lesions form 
coin-sized patches we speak of psoriasis nummularis. A 
single patch may grow to be two inches in diameter, or 
even larger, and preserve its circular shape. But the large 
patches are usually formed by the coalescence of several 
smaller patches, and may attain to a size sufficient to cover 
the greater part of a limb, or even the trunk. Its circular 
outline is now lost and the patch has a more or less scal- 
loped, indented border bearing so strong a resemblance to 
the maps drawn by children, that Piffard suggested the term 
psoriasis geograpliica for it. But the more usual name is 
psoriasis diffusa. After a patch has reached a certain size 
it may clear up in the centre and form a ring, and in this 
way we have psoriasis circinata. Several of these rings 
may meet at their circumference, when the points of contact 
will disappear and gyrate figures will be formed. When 
the eruption is so general as to involve the whole or the 
greater part of the body, we speak of it as psoriasis univer- 
salis. Not infrequently these cases bear a striking resem- 
blance to dermatitis exfoliativa. 

Every case of psoriasis does not exhibit all these varieties, 
because the disease may stop short at any period of its 
evolution. But in any case there is apt to be a number of 
variously sized lesions. Whatever the size of the patch may 
be, it will always be observed that the redness extends a 
little beyond the scales. The amount of the scaling will 
vary. Sometimes the scaling will be but slight ; sometimes 
it will be so abundant that it will heap up into such crust- 
like masses as to suggest the adjective rupioide. The scales 
are constantly being shed, and as constantly renewed. They 
may be readily scraped off with the nail, and if this is care- 
fully done a delicate glistening membrane will be exposed, 
under which will appear dot-like red points. That is, we 
have removed the epidermis and exposed the mucous layer 
of the skin, the red points being the tops of the slings of 
bloodvessels of the papillae. This is thought by some to be a 



psoriasis. 383 

characteristic of psoriasis, but with care it may be produced 
in other diseases. 

The color of the scales is silvery white or grayish. 
Darker scales are due either to the deposition of dust, or the 
admixture of blood. The color of the patch will vary from 
a pinkish red to a dark red, the darker color being seen 
upon the legs, where the color of all lesions is darker on 
account of the partial stasis in the flow of blood. The 
disease is always a dry one, there being absolutely no dis- 
charge feature in its course. The patches are sharply de- 
fined, but so little raised that they can be nearly all scratched 
away. 

While psoriasis may occur anywhere on the body, and, as 
we have seen, may become universal, its most frequent loca- 
tions are the extensor surfaces of the limbs, elbows, and 
knees, or rather the face of the tibiae just below the knee, 
and the scalp. It may occur upon the two first locations 
alone. When it occurs on the scalp careful examination 
will show some lesion elsewhere on the body, and we will 
usually find a little patch in front of the ears, and very 
often there will be a red scaly line on the forehead just in 
front of the hair line, a feature that is as striking and as 
characteristic of psoriasis as the corona veneris is of syphilis. 
The hair does not fall, as a rule. In some cases, however, 
we may have transient or permanent alopecia. The whole 
scalp may be covered with a continuous patch, or distinct 
scaly patches may form as on the body. In any event the 
border of the patch will be sharply defined. 

The palms and soles are very rarely the seat of the dis- 
ease, and then only as part of general psoriasis. It is true 
that a few cases have been reported in which it has been 
said even to be located upon one hand alone, and this by 
competent observers. But the probabilities are all in favor 
of such cases having been either syphilis, which is most 
likely, or squamous eczema. The disease is bilateral and 
sometimes may show a decided tendency to symmetry. 

In old inveterate cases there may be considerable thicken- 
ing of the skin, a feature that is usually wanting, and fissures 
may form about the joints that may be painful and bleed. 



384 DISEASES OF THE SKIN. 

This may also occur on the scrotum, or the trunk where the 
skin is in folds. 

The nails are affected in some cases, becoming opaque, 
lustreless, furrowed transversely, discolored, and sometimes 
cracked ; while they are raised from their beds by the 
accumulation of scales underneath them. All the nails are 
rarely diseased at the same time ; usually it is but one or 
two nails on each hand or foot. Sometimes the disease is 
limited to a strip along the side of one nail 

There is no constitutional disturbance in this disease, the 
patients usually being in as perfect health as the majority 
of mankind. Sometimes they will have pains in the joints 
that are regarded as rheumatic by some, and as neurotic by 
others. Itching is very often an annoying symptom. 
Sometimes it is entirely wanting. 

The course of the disease is variable. Although it is 
always chronic, it presents at times acute symptoms. Re- 
lapses are the rule to which there are few exceptions. In 
some cases the skin will be entirely free of all trace of the 
disease for months or years. In most cases this freedom is 
only partial; even though the patient thinks he is clean, 
some little spot will be discoverable. The duration of each 
patch is also variable. It may disappear in a few weeks or 
remain for months. Most cases are better in summer, to 
become worse in winter. When the patches disappear they 
do so completely, though a slight amount of scaling may 
be present for a short time. In a few very rare cases a 
chronic psoriatic patch has become papillomatous, and then 
epitheliomatous. 

Etiology. Various theories have been advanced in the 
etiology of psoriasis, and some facts have been established by 
our study. We know that the disease is hereditary in a 
number of cases. Greenough 1 found the proportion as high 
as one-third. It may occur at any age. Kaposi has re- 
ported a case at eight months of age. It usually is a disease 
of early adult life, making its first appearance before the 
thirtieth year. It is rare after the fiftieth year. It affects 

1 Boston Med. and Surg Journ., 1885, cxiii. 163. 



psoriasis. 385 

both sexes, and all conditions of life. These things we 
know. 

While the majority of patients seem to be in the best of 
health, some are rheumatic, or gouty. A lowered condition 
of the general health seems, in some cases, to favor an out- 
break either of a primary attack or of a relapse. Thus it is 
no uncommon thing to see the disease in women grow worse 
during pregnancy or lactation. Mal-assimilation or diges- 
tive disorders also seem to aggravate or provoke the disease, 
Hardaway even affirming that he has known the inordinate 
eating of oatmeal to cause the disease, while Gowers 1 reports 
cases produced by the ingestion of borax as a medicine. 
Polotebnoff 2 has written an elaborate thesis to show that 
the disease is a vasomotor neurosis, affirming that in a 
majority of cases there will be found evidences of either 
trophic or vasomotor disturbances, or a history of more or 
less profound nervous troubles either in the patient or his 
family. A number of cases following fright or nerve-shock 
have been reported. In the VierteljaJirscTirift f. Dermat. 
u. Syph. for 1878, Lang brought out his parasitic theory, 
and in No. 208 of Volkmann's Sammlung klinische Vor- 
trdge the thesis is further elaborated, the fungus being 
represented by illustrations. He has found some support 
from other observers, but the theory has not gained credence 
from the best authorities. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the location 
of a patch of psoriasis. 

Pathology. Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 
keratolysis, or an anomaly of cornification in which an im- 
perfect corneous layer is formed. Some teach that the pro- 
cess begins in the rete, and the changes in the corium are 
secondary ; while others hold the reverse view. Lang 
names his parasite epidermedopJiyton y and describes it as 

1 Lancet, October 24, 1884. 

2 Monatshefte f. prakt. Dermat., 1891, Erganzungsheft No 1. 

17 



386 DISEASES OF THE SKIN. 

composed of mycelia and spores, either disseminated or in 
groups, which are so delicate as to be found only with very 
high powers. 

Diagnosis. A typical case of psoriasis presenting round 
or oval, variously sized red dry patches covered with thick 
silvery white scales, scattered more or less generally over the 
body, but showing a marked preference for the extensor sur- 
faces of the extremities and specially of the elbows and knees, 
is readily recognized. In some less typical cases it needs to 
be differentiated from syphilis, eczema, seborrhcea, derma- 
titis exfoliativa, lichen ruber acuminatus and planus, Unna's 
seborrheal eczema, and possibly from lupus erythematosus. 
From the squamous syphilide as a secondary stage of the 
disease it differs by showing preference for the extensor sur- 
faces of the limbs and the posterior surface of the trunk, 
though there are many exceptions to this rule. The 
syphilide is not so scaly ; its red is darker, more ham- 
colored ; the lesions are more infiltrated, giving a more shotty 
feeling to the finger ; they do not itch ; they run a more 
acute course, and are of more uniform size, never exhibiting 
the patchy character of psoriasis. It is usually easy to 
establish the presence of other manifestations of syphilis, 
such as sore-throat, pains in the bones, fall of the hair, and 
perhaps the remains of the initial lesion. The late scaly 
syphilide is never general ; is unsymmetrical, usually con- 
sisting of one or two groups of lesions that show no tend- 
ency to affect the elbows and knees. The lesions are more 
raised and prone to leave scars. There will also be the his- 
tory of past syphilides to guide us, and an absence of those 
relapses so common and characteristic of psoriasis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is ; the patch is more infiltrated ; the scaling is less, 
the scales being thinner ; exudation can be readily induced ; 
and a history of moisture at some time will be found. The 
patch of eczema is generally less sharply defined, and is 
more apt to shade off into the surrounding skin. If the 
scales of a psoriatic patch are removed, a delicate mem- 
brane is left showing red dots — the tops of the bloodves- 



psokiasis. 387 

sel slings in the papillae ; if the same thing is done in 
eczema a discharging surface will be left. 

Seborrhoea may simulate a psoriasis when it occurs in 
patches on the chest, or as thick crusts on the scalp. The 
patches on the chest have a more yellow color and their 
scales a more greasy feel than is the case in psoriasis. On 
the scalp the crusting of seborrhoea does not occur in such 
sharply defined patches, and its crusts are very greasy. 
In either case, if it be one of psoriasis we will be sure to 
find one or more typical lesions somewhere on the trunk. 

It is quite impossible to differentiate a true case of derma- 
titis exfoliativa at first sight from one of general psoriasis. 
If it does arise from psoriasis there will be a history of its 
gradual spread from typical lesions quite different from what 
obtains in true dermatitis exfoliativa, which is more rapid in 
its evolution. Psoriasis is rarely so absolutely universal as 
is dermatitis exfoliativa. Watching the case for a time will 
establish the diagnosis. If psoriasis is the malady it will 
declare itself after a time by the diffused redness clearing 
up and typical psoriatic patches showing themselves. 

Lichen ruber acuminatum presents small pointed papules 
upon the trunk at first, and not the large, much-scaling 
papules upon the extensor surfaces of the limbs of psoriasis. 
When the disease becomes general we will have the history 
of these lesions, and a much greater thickening of the skin. 

Lichen planus occurs by preference on the flexor rather 
than the extensor aspects of the limbs, and in the form of 
a flat, shining, angular, smooth papule, rather than a round, 
freely scaly one. The color of its patch is violaceous and 
not bright red. If it becomes universal it does so evidently 
by the springing up of new small lesions between the old 
ones, and not by the peripheral growth and coalescence of 
those already existing. The thickening of the skin is also 
much greater than in psoriasis. 

In the diagnosis from seborrhoeal eczema, Unna lays 
great stress upon four points : 1. Seborrhoeal eczema 
spreads from above downward, mostly in the middle line of 
the body, and its lesions are quite stationary in character ; 
while psoriasis begins on the elbows and knees, and more 



388 DISEASES OF THE SKIN. 

speedily affects the whole body. 2. There is always a his- 
tory of a seborrheal affection of the scalp in seborrheal 
eczema. 3. The scales of seborrheal eczema are fatty and 
crumbling, and the patches are yellowish ; in psoriasis the 
scales are white and friable, not greasy, and the patches are 
bright red. 4. The proneness of the patches of seborrheal 
eczema to form bow- shaped figures, or rings more or less 
broken. Psoriasis may be circinate, but the margins of the 
figures are not so narrow and not follicular as they may be 
in seborrrheal eczema. 

Treatment. Though external treatment alone will 
remove the evidences of psoriasis upon the skin, producing 
a cure of the disease — if that may be said of a disease that is 
almost sure to relapse — we sometimes can procure more 
prompt results by a combination of internal and external 
remedies. The first inquiry in all cases should be made as 
to the general condition of the patient, and we should 
endeavor to establish in him as perfect a state of health as 
is possible. A restricted diet certainly does have a good 
deal of influence in causing an amelioration of the disease. 
No hard and fast lines can be set in this respect. Under my 
esteemed teacher, Prof. Geo. Henry Fox, who is a strong 
advocate of dieting in skin diseases, I have seen some 
patients improve under a strictly vegetable diet, and others 
do equally well on a dietary composed largely of milk and 
animal food. A stout, evidently overfed, plethoric patient 
will be benefited by cutting off all, or nearly all, meat. In 
this class of patients it is a good plan to insist upon a milk 
diet for a few days. An anaemic, underfed patient will, on 
the other hand, improve under a more liberal dietary. 
Alcoholics, and especially malt liquors, should be interdicted 
in all cases, as well as rich gravies and highly spiced foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 
tion as remedies for psoriasis, though it must be confessed 
that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most general 
practitioners as the remedy for psoriasis. It does do good 
in this disease, but at the same time it is not to be con- 



psoriasis. 389 

sidered as a true specific. In acute cases it aggravates the 
disease and should never be given. In chronic cases that 
have proved very stubborn, it may be tried, and sometimes 
it will produce a speedy cure. The vast majority of cases 
will do quite as well without it. It may be given in the 
form of Fowler's solution with or without the wine of iron, 
and administered in water three times a day after meals. 
The initial dose for an adult should be about three drops, 
and the amount should be gradually increased until the 
limit of toleration is reached. Crocker thinks that the effi- 
ciency of this form of arsenic is enhanced by the addition 
of half a drachm of the tincture of lupulus to each dose. 
The Asiatic pill is the favorite mode of using arsenic in 
Vienna. It is composed, according to Kaposi, of — 

R. Pulv. ac. arseniosi, 75 

Pulv. piperis nigrse, 6 

Gummi acaciae, 1 50 

Pulv. althse. rad., 2 

Aquae, q. s. M. 

Div. in pil. no. c. 

One pill is given after meals, and the dose is increased 
gradually every four or five days until ten or twelve 
are taken a day, unless some constitutional disturbance is 
caused before then. The method of increase is by first 
giving one pill after each meal ; then two pills after break- 
fast, and one after the other two meals ; and then two after 
breakfast, two after the midday meal, and one in the even- 
ing, and so on. Or we may make use of the tablet triturates 
of arsenious acid with piperina, giving those containing one- 
twentieth of a grain of the arsenic in the same manner as 
the Asiatic pills. Any other preparation of arsenic may be 
used. Hypodermatic injections of the metal have been em- 
ployed with success, but it would be hard to induce an 
American patient to endure this method. The administra- 
tion of the drug must be persisted in for a long time, and 
it may prove curative by itself. 

Alkalies that act as diuretics are often very helpful, quite 
apart from any indication for their use on account of gout or 
rheumatism. A beginning psoriasis, or even a case of some 



390 DISEASES OF THE SKIN. 

duration, will be favorably influenced by the administration 
of the acetate or citrate of potassium in fifteen-grain doses 
before meals, well diluted, and followed by drinking half a 
glass of water. The undoubted eflicacy of the large doses of 
the iodide of potassium as recommended by Haslund, 1 may 
depend in part, at least, upon its diuretic action. He gives 
the salt in increasing doses so that as much as 600 grains 
have been administered to one patient during the day. 
When assistant physician to the New York Skin and Can- 
cer Hospital, on Dr. G. H. Fox's division, I tried Haslund's 
plan in several cases. They certainly were greatly bene- 
fited. The objections to this method are the expense of the 
drug and the danger of the sudden production of poisoning, 
shown by palpitation of the heart, severe headache, and 
faintness, and necessitating either keeping the patient in a 
hospital or under the constant attendance of a physician. 

Turpentine oil is highly commended by Crocker as 
follows : It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 
dose is ten minims three times a day after meals. It may 
be increased by five or ten minims at a dose until the 
patient, if tolerant of it, is taking thirty minims three times 
a day. Barley-water must be freely drunk during the day 
to prevent any bad effect on the kidneys, and the last dose 
of the turpentine should not be taken later than six or 
seven o'clock in the evening. Dyspepsia and irritability of 
the urinary organs contra-indicate its use. 

The wine of antimony in five- to ten-minim doses is 
recommended by Mr. Malcolm Morris as efficacious in acute 
cases. 

Chrysarobin by the mouth, one-sixth of a grain in sugar 
of milk three times a day, and increased to one or two 
grains at a dose, acts well in some cases, but is very apt to 
cause so much nausea and vomiting as to compel its discon- 
tinuance. 

Polotebnoff advocates the use of bromide of potassium, 
believing the disease to be a neurosis ; and of ergot. 

1 Vierteljahr. f. Derm. u. Syph , 1887, xiv. 677. 



PSORIASIS. 



391 



External treatment. Before making any application to 
the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with sim- 
ple oil, or vaseline, combined with attention to diet, will pro- 
duce a cure. Generally we must resort to more stimulating 
remedies. The most useful and most promptly curative 
external remedy is chrysarobin (chrysophanic acid). The 
objections to it are its tendency to produce an acute derma- 
titis and its permanent staining of everything with which 
it comes in contact. These unpleasant effects may be in 
part overcome by combining the drug with flexible collodion 
or traumaticin, but only in part. The dermatitis is always 
most marked upon those parts in which there is laxity of the 
skin, and if it is used on the face it is prone to produce 
great swelling about the eyes. Care must be taken not to 
get it in the eyes, as it causes violent conjunctivitis. These 
effects forbid its .use upon the face or scalp. 

The most active form in which to use the drug is in an 
ointment as of lard, lanolin, or vaseline. Bassorin and 
plasment are excipients brought out in 1891. Bassorin 
was introduced to the profession by Dr. Geo. T. Elliot, 1 of 
New York, and shortly afterward by Prof. Pick, 2 of Prague. 
Plasment originated with Messrs. Dagget and Ramsdell, of 
New York. These excipients have the merit of not being 
greasy, and can be readily and entirely removed by means of 
water. Flexible collodion or traumaticin, the liquor gutta- 
percha, are good excipients. 

The strength of chrysarobin should not exceed one 
drachm to the ounce, as a rule, though in exceptional cases 
it may be used in greater strength. Its activity is increased 
by the addition of salicylic acid (3 per cent.), and then it is 
best to use it in a lower percentage, even 5 per cent, being 
active enough. An alkaline bath before using the chrysa- 
robin increases its potency. If we use an ointment, it should 
be thoroughly rubbed in once a day after the scales are 



1 Journ. Cutan. and Gen.-urin. Dis., 1891, ix. 48. 

2 Vierteljahr. f. Derm. u. Syph., 1891, xxiii. 633. 



892 DISEASES OF THE SKIN. 

removed. If our vehicle is bassorin, plasment, collodion, or 
gutta-percha solution the spots should be painted over as often 
as the film that the application leaves falls. The patient 
should always be warned against getting the drug in his eyes. 
A favorite formula of Dr. Geo. H. Fox is the following : 

R. Chrysarobin., \ 2rarts 

01. cadi, / aa ^Parts- 

Ac. carbolici, 1 part. 

Ac. oleic, 50 parts. M. 

If the chrysarobin produces too great a reaction, it 
must be stopped and the skin treated with vaseline and 
starch powder, or an alkaline wash. The action of the 
drug upon the skin is peculiar. It stains the skin about the 
patches of a mahogany-red, while the patches become 
smooth and white. It discolors the nails and the hair, but 
after a time the staining disappears. Not so the staining 
of the clothing, which is permanent. It is said that it can 
be somewhat lessened by soaking the clothes in plain water 
before using soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. 
It is still a reliable remedy, but it cannot be used over 
the whole body in a general psoriasis on account of the 
danger of absorption of the mercury. It is the pleasantest 
and promptest application to the scalp and face, and can 
be used there while chrysarobin is used on the rest of 
the body. Other mercurial ointments, such as that of the 
yellow oxide, and a dilute ointment of the nitrate, may be 
used. Lang has found the bichloride of mercury in collo- 
dion in J to ^ per cent, strength a good application. It 
would probably be an unsafe one in a case of any extent. 

Tar is another old and reliable remedy, still much used 

in France. It may be employed in an ointment, or oil, or 

dissolved in alcohol. The oil of cade, oil of birch, or pure 

tar may be used in the strength of half a drachm to four 

drachms to the ounce. In Paris the following is sometimes 

used : 

& . Glycerole of starch, \ 1QQ 

Oil of cade, / aa 1UU parts ' 

Green soap, 5 " M. 



psoriasis. 393 

This is to be rubbed in at night, the patient is to sleep in 
a flannel gown, and wash the stuff off in the morning. 
Kaposi recommends the following : 

K . 01. rusci, 50 parts. 

Etheris sulphuris, \ aa 75 " 

Alcoholis, j 

Filter, and add 

01. lavandulae, 2 " M. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symptoms. 
Pyrogallol (pyrogallic acid) is efficacious, but can only be 
used in cases in which the eruption is not extensive, on 
account of its poisonous action when absorbed. It may be 
used in the strength of about 10 per cent, in ointment. It 
stains the skin, but causes less inflammatory reaction than 
chrysarobin does. 

Thymol was introduced by Crocker. It may be used as 
an ointment or lotion in the strength of 15 grains to 3 
drachms to the ounce. As it is colorless and of pleasant 
odor it is suitable for use on the face. The same authority 
advocates the use of turpentine locally. He uses the oleum 
pini sylvestris with sufficient oil of lavender or essence of 
lemon to cover its odor. If used undiluted the skin must 
be smeared with vaseline to prevent its cracking. It is 
better to use it diluted with olive oil, 5j oil of turpentine to 
5vij of olive oil, the proportion of the oil of turpentine being 
increased as the skin becomes accustomed to it. The addi- 
tion of oil of cade or oleum rusci to the mixture increases 
its efficacy. 

Salicylic acid, 5 to 20 per cent, strength, will remove the 
scales and in some cases will prove curative. The soap 
treatment, as described in chronic eczema, is of great value 
in some chronic circumscribed cases. Sulphur ointment, 
oleate of copper, " rufigallic" acid, 10 per cent, in ointment, 
resorcin, have all done well in some cases. Hydracetine, 
anthrarobin, and aristol are among the latest remedies, but 
have not proved themselves as active as some of the older 
ones. 

Some patients have found benefit from the use of natural 

17* * 



394 DISEASES OF THE SKIN. 

mineral waters at spas. It is possible that much of the bene- 
fit so obtained is from the prolonged and regulated bathing. 
Wearing rubber clothing next the skin, or with a fine piece 
of muslin between the rubber and the skin to avoid the pro- 
duction of eczema by the rubber, will soften and remove the 
scales, and hasten the disappearance of the patches. 

Gallacetophenone in 5 to 10 per cent, strength as oint- 
ment or dissolved in collodion may be tried, but is not as 
good as chrysarobin. 

Peognosis. A cure of psoriasis may be promised with a 
fair degree of certainty as far as the removal of the erup- 
tion then out is concerned. But no promise can be made 
that the disease will not relapse. In this respect psoriasis 
resembles rheumatism and gout. While most relapses are 
readily removed in the course of a few weeks, in some cases 
one or more patches will be remarkably obstinate. 

Psorospermosis Follicularis Cutis is the name given by 
French writers, notably by Darier, 1 to a disease of the skin 
cases of which had previously been reported under the names 
of lichen spinulosum (Hutchinson), ichthyosis sebacea cornea 
(Wilson), acne sebacea cornea (Guibout), ichthyosis follic- 
ularis (Lesser), keratosis follicularis (Morrow and White), 
acne cornee (Leloir and Vidal), cacotrophia folliculorum (T. 
Fox), and sauroderma. The title psorospermosis was given 
by Darier because he believed that he had found certain para- 
sites belonging to the order of protozoa, which have been 
named psorosperms in causal connection with the disease. 
(For description of the disease see Keratosis follicularis.) 

Pterygium (Te 2 r-i 2 j / i 2 -u 3 m) is simply an overgrowth of the 
normal nail-fold at the proximal end of the nail so that it 
covers, to a greater or less extent, the lunula. It may be 
cut off. 

Purpura (Purp r u 2 r-a 3 ). Synonyms : Hsemorrhoea pete- 
chials ; (Ger.) Blutfleckenkrankheit. 

Symptoms. By this term is meant a hemorrhage into 
the skin which is not caused by direct traumatism. It is 

1 Ann. de Derm, et de Syph., 1889, x. 597. 



PURPURA. 395 

always readily recognized by the red, purple, or blue-black 
color that it causes, which cannot be made to disappear by 
pressure. The hemorrhage may take place into any part of 
the skin ; into the subcutaneous tissues ; or into any of the 
glandular apparatus of the skin. It occurs with sudden- 
ness, and produces variously-sized lesions to which certain 
names have been applied. When they are small, from pin- 
point-size to perhaps an inch in diameter, they are called 
petechia*. When occurring in the form of more or less 
long streaks they are called vibiees. Large bruise-like 
lesions with more or less swelling are ecchymoses. Blood 
tumors of all sizes are ecchymomata or hcematomata. The 
color of all purpuric lesions depends upon their age. When 
first formed they are bright red, claret, or purple. Before 
disappearing they pass through various shades of color such 
as are seen after an ordinary bruise, becoming blue-black, 
greenish-black, or brownish. These changes are due to the 
gradual absorption of the effused blood and the haematin 
deposited from the blood globules. There is no definite 
time for complete absorption to take place, but eventually 
no trace is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair fol- 
licles we will have papules formed. If between the layers 
of the epidermis, hemorrhagic bullae will result. Hemor- 
rhage into sweat glands will give rise to hsematidrosis. As 
complications of other dermatoses hemorrhage may occur, as 
in urticaria, pemphigus, and eruptive fevers, but these should 
not be elevated into special varieties of purpura. 

There are three varieties of purpura, namely, purpura 
simplex, purpura hsemorrhagica, and purpura rheumatica. 
It is convenient for us to preserve these varieties for a time, 
though the results of the latest studies seem to indicate that 
the second variety is but a more developed form of the first, 
cases of simple purpura having been seen to run into the 
hemorrhagic form. By Crocker and others the third variety 
is regarded as a form of erythema exudativum. It, too, 
has been seen to run into the hemorrhagic form. 

Purpura Simplex is the most common variety, and usu- 
ally takes the form of petechise, the lesions being round or 



396 DISEASES OF THE SKIN. 

oval, or irregular in shape, or even circinate. Duhring de- 
scribes a case of this rare form, as does Stelwagon. 1 The 
lesions appear suddenly, generally without antecedent symp- 
toms, and often at night. Like other forms of purpura, the 
lower extremities are the most common seat of the eruption, 
especially their flexor aspects, but any part of the skin may 
be attacked, as also the mucous membranes. Crocker 
affirms that in children the lesions appear first upon the 
neck and upper part of the back. The lesions appear in 
crops, and most often are symmetrical. There may be but 
a single outbreak, and the whole disease may be at an end 
in a week or two. But it may be prolonged for many weeks 
by a succession of outbreaks. There is usually no constitu- 
tional disturbance, and the only things the patient complains 
of are the spots, and perhaps some itching. There may be 
lassitude, malaise, and slight elevation of temperature. 
Recovery is the rule. Exceptionally purpura simplex passes 
over into 

Purpura Hcemorrhagica. This form is also called mor- 
bus macuhsus Werlhoffii and land scurvy. It usually 
begins as such, and is heralded by pronounced malaise, 
headache, and perhaps convulsions. It begins without pro- 
dromata. It differs from the previous variety by the more 
extensive hemorrhages that take place, ecchymoses forming 
rather than petechia, and by free bleeding from all the 
mucous membranes — nose, mouth, stomach, urethra, rectum, 
vagina. These are so copious and uncontrollable at times 
that the patient will literally bleed to death in a few hours. 
Sudden death may also be caused by hemorrhage into the 
meninges and brain. An excellent study of this fulminating 
form of purpura has been made by Lock wood. 2 In his case 
there was a rise of temperature to 106.2° F. just before 
death, and the patient died in about sixty hours from the 
onset of the disease. He collected thirty cases, in thirteen 
of which the patients died from acute anaemia, internal 
hemorrhages, or septic infection, the shortest duration of any 

1 Journ. Cutan. and Gen -urin. Dis., October, 1887. 

2 Medical Kecord, February 7, 1891. 



PURPURA. 



397 



one case being seven hours ; in eight cases death was due to 
cerebral hemorrhage ; and in four cases the patients were 
pregnant. Happily all cases of hemorrhagic purpura are 
not fatal. In them the bleeding is moderate in amount, and 
the patient is gradually restored to health. Relapses may 
occur. 

Purpura Rheumatica. This is also called peliosis rheu- 
matica. 'It resembles purpura simplex in every way, except- 
ing that the outbreak of the eruption is preceded or followed 
by pain in the joints accompanied by swelling, the malaise 
is more marked, and there is often rise of temperature. 
The eruption is often most abundant about the joints. The 
acute symptoms subside in two or three days, but relapses 
are frequent. True rheumatism maybe present at the same 
time. Valvular heart lesions have been reported to occur 
after this variety of purpura, even without true rheumatism. 
Rarely this variety may pass over into the hemorrhagic 
form. 

Etiology. Many causes have been assigned to account 
for the occurrence of purpura. We know that it may 
occur at any period of life, in both sexes, and in the most 
varying conditions of health. There is no doubt that pur- 
pura occurs as a symptom in different diseases and cachexia ; 
after the ingestion of certain drugs, and under other cir- 
cumstances too numerous to catalogue here. Here we can 
readily surmise that one or both of two things have 
occurred, namely : a change of the blood itself that allows 
of its passing through the walls of the vessels ; or a 
change in the vessel walls themselves that permits the blood 
to pass through them. Purpura has been noted after the 
loosening of some artificial support to a part of the body, 
as with a tight bandage continued for a long time. It 
occurs not infrequently in old age. In both these con- 
ditions it is due to a weakening of the tone of the vessels. 
In the former case matters right themselves in a few days — 
a happy conclusion that cannot be anticipated in the latter 
case. Weakness of vesicular walls may also be the cause of 
those somewhat rare cases of purpura without cachexia seen 
in infants. Other cases of purpura are due to small thrombi 



398 DISEASES OF THE SKIN. 

lodging in the smaller vessels. Some cases seem to be due 
to vasomotor or trophic nerve action causing either sudden 
alterations in the calibre of the vessels or degenerations in 
their walls. Recurring purpura has been noted about the 
point of greatest pain in neuralgia. 

The microbian and infectious origin of purpura is stoutly 
defended by some authorities. Letzerich 1 published a 
brochure on this subject in 1889, in which he described the 
" bacillus purpure hemorrhagica Letzerich " as the cause 
of the disease. This has sharp angles and edges, is readily 
cultivable, and pure cultures injected into rabbits give rise 
to hemorrhages either spontaneously or on slight trauma. 

Diagnosis. The diagnosis of purpura is easily made. No 
other disease produces brigbt-red, slightly elevated lesions the 
color of which cannot be made to disappear under pressure. 
From flea-bites they are distinguishable by the absence of a 
central punctum. Purpura hemorrhagica bears a close 
resemblance to scurvy, but in the latter a dietary deficient in 
vegetables is a marked etiological factor ; there is also 
greater prostration, swelling of the gums, loosening of the 
teeth, and brawny swelling of the limbs. It is possible 
that further investigations of scurvy may show that it is but 
a form of purpura hemorrhagica that has been modified by 
diet. 

Treatment. In simple purpura there is not much to be 
done except to put the patient in as good a hygienic condi- 
tion as possible and relieve symptoms. In peliosis rheu- 
matica and purpura hemorrhagica, the patient should be 
kept absolutely quiet in bed, his diet made of the most 
nutritious and easily assimilable kind, and ergot and iron 
administered. Of course, if there is hemorrhage from the 
nose, vagina, or other mucous cavity an effort must be made 
to stop the flow by means of a tampon, ice, hot water, or 
any method that experience has proved useful. Ergo tine 
may be employed hypodermatically ; and turpentine; dilute 
sulphuric acid ; nitrate of silver in pill form -| to J- of a 
grain three times a day ; and other astringents, have been 

1 Monatshefte f. prakt, Permat,, 1889, p. 312. 



PUSTULA MALIGNA. 



399 



found useful. Letzerich recommends for bleeding from the 
gums — 



R . Tinct. ratanhise, 
Tinct. iodini, 



10 parts. 
5 " M. 



of which 10 drops are to be put in a wineglassful of water. 
For this purpose other astringents, as tannin, alum, and the 
like may be used. 

Prognosis. From the beginning of a case it is not pos- 
sible to say how it will turn out. We should therefore be 
very guarded in our prognosis. Most cases met with do 
terminate favorably. Some apparently desperate cases do 



recover. 



Malignant 



Pustula Maligna. Synonyms : Anthrax 
pustule ; (Fr.) Charbon. 

This is a disease of cattle, sheep, and horses, in which it 
is called splenic fever, and is due to local inoculation with 
the bacillus anthrax often through the agency of flies. If 
the bacillus gain access to the internal organism it produces 
a rapidly fatal general disease with no skin lesion. In the 
human the exposed parts — face, hands, and neck — are the 
most frequent sites of the disease. In a day or two after 
inoculation, the patient notices a burning or itching of the 
affected part and the formation of a livid red papule upon 
which a bulla or pustule soon forms. This ruptures, the 
red spot changes into a black gangrenous eschar, the parts 
around it become indurated, oedematous, of dusky red hue, 
and studded with small vesicles or pustules. There is 
marked involvement of the lymphatics, and enlargement of 
the neighboring glands that may suppurate. In favorable 
cases the slough separates, and healing by granulation takes 
place. In fatal cases the gangrenous process extends 
rapidly, symptoms of septic infection declare themselves, 
and the patient succumbs to the disease in from two to eight 
days. In all cases there is more or less constitutional dis- 
turbance. 

Diagnosis. The diagnosis of malignant pustule is made 
mainly by the rapidity with which the disease develops ; the 
presence of the gangrenous patch with the hard indurated 



400 DISEASES OF THE SKIN. 

tissues about it ; and the severity of the constitutional symp- 
toms. The finding of the bacillus will verify the diagnosis. 
Treatment. The total excision of the diseased patch by 
means of a free incision is the most radical and effectual 
treatment for the disease. Injection of iodine or a 5 per 
cent, solution of carbolic acid under the eschar are good 
methods of treatment. The hyposulphite or sulphite of 
soda, and large doses of quinia, are worthy of trial. 

Quinquaud's Disease. See Folliculitis decalvans. 
Radesyge. See Lepra. 

Red Gum. "An obsolete term for various transitory erup- 
tions in teething children." (Foster.) Commonly this is 
miliaria. 

Rheumatokelis. A term applied by Fuchs to purpura 
occurring with rheumatism. 

Rhinophyma (Ri 2 n-o-fi'ma 3 ) is the term used to designate 
that form of hypertrophic rosacea in which pendulous tumors 
develop on the nose. These may attain so great a size that 
they will hang down over the mouth. 

Rhinoscleroma (Ri 2 n-o-skle 2 rVma 3 ). Synonyms: (Fr.) 
Rhinosclerome ; (Ital.) Rinoscleroma ; Perisarcoma. 

Symptoms. This is an exceedingly rare form of disease 
that was first described by Hebra and Kaposi. It affects 
almost exclusively the nose and its mucous membrane, and 
assumes the form of flat or slightly raised, sharply defined, 
isolated or confluent, very hard, elastic plates, tumors, or 
nodes which are painful on pressure. These lesions are 
located in the skin or mucous membrane of the septum of 
the nose, or in the alse and the neighboring parts of the 
upper lip. They can be raised from the underlying parts, 
but the skin is so infiltrated that it can move only with the 
growths. The color of the skin may be normal, or bright or 
dark-brownish red, and looking like a keloid or hypertro- 
phied scar. The contiguous skin shows no abnormalities 
whatsoever. The epidermis over the growths often shows 
rhagades from which exude a viscid secretion which dries 
jnto yellowish adherent scabs. 



RHINOSCLEROMA. 401 

The disease begins as a thickening and hardening of 
the septum or one or both alse without inflammatory reaction 
or pain. Slowly the nose becomes deformed, broad, and flat, 
and at last by progressive thickening of both septum and 
alse the nostrils become occluded. The process may involve 
the lips so that the opening of the mouth becomes greatly 
lessened, and may affect the gums. More frequently it pro- 
ceeds backward along the nostrils on to the velum palati. 
The growth shows no tendency to ulceration or retrograde 
metamorphosis. At the most superficial parts excoriations 
occur. Late in the disease the teeth may loosen and fall out, 
and the gums may atrophy. The disease may begin in 
some cases in the pharyngeal vault. The epiglottis and 
larynx may be involved in the process, and aphonia, suffo- 
cative or epileptic-like attacks may occur. There is no 
constitutional disturbance, and the only subjective symptoms 
are those of discomfort on account of the interference with 
respiration. The disease is steadily progressive ; shows no 
tendency to recovery ; and recurs rapidly when the diseased 
parts are cut away. 

Etiology. All conditions of men are affected, and both 
sexes with about equal frequency. It usually begins be- 
tween the fifteenth and fortieth year. It is most frequent 
in warm climates. A bacillus has been found in the tissues 
that is regarded by some as the cause of the disease. It is 
described as short, thick, ovoid, capsulated, in free groups 
and in cells. 

Diagnosis. The location upon the nose and upper lip 
alone, the ivory-hardness of the growths, and their pro- 
gressive course without tendency to ulceration or softening, 
will establish the diagnosis as against syphilis, epithelioma, 
and sarcoma. Keloid rarely occurs upon the nose, and 
never runs the characteristic course of rhinoscleroma. 

Treatment. Treatment is very unsatisfactory. The 
growths may be excised er curetted away, but neither pro- 
cess will assure against a relapse. The nostrils may be 
kept open by means of sponge tents and the like. Besnier 1 

1 Annal. Derm, et Syph., 1891, ii, 603. 



402 DISEASES OF THE SKIN. 

recommends boring into the tissues with points of chloride 
of zinc for the purpose of giving passage to air. Pyrogallic 
acid, 10 per cent, in vaseline, has been recommended as 
of value. 

Prognosis. The prognosis is bad. The disease is pro- 
gressive, and threatens life by suffocation on account of 
involving the larynx. 

Rhus Poisoning. See Dermatitis venenata. 

Ringskurv. See Trichophytosis capitis seu corporis seu 
barbae. 

Ringworm. See Trichophytosis capitis seu corporis seu 
barbae. 

Rissopola Lombarda. See Pellagra. 

Ritter's Disease. See Dermatitis exfoliativa neonato- 
rum. 

Rodent TTlcer. See epithelioma. . 

Rosacea (Ros-a'ce-a 3 ). Synonyms : Acne rosacea ; 
Grutta rosacea seu rosea ; Acne erythematosa ; (Fr.) Acne 
rosee, Couperose, Rosacee, Rosee ; (Ger.) Kupferrose, 
Kupferfinne, Kupfrigegesicht. 

A chronic disease of the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that often occur with the disease 
are not true acne pustules, it is best to drop the "acne'' 
from its title. 

Symptoms. Rosacea is one of the more common of skin 
diseases, and is peculiar in affecting only the middle third 
of the long diameter of the face, the forehead, nose, and 
adjacent portions of the cheeks, and the chin. The nose 
may be affected alone, and in many cases the forehead 
escapes entirely. The disease has three forms or stages. 
The first consists in a simple redness of the affected skin 
with more or less well-marked dilatation of the capillaries. 
In the second stage there is an added element of superficial 



ROSACEA. 403 

papules and pustules, and perhaps nodules. In the third 
stage there is marked hypertrophy of the skin. The pro- 
cess may stop at any stage. An oily seborrhoea may com- 
plicate the disease, Unna even claiming that his seborrhoeal 
eczema is the first stage of all cases of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot fluids, 
exposure to cold, and the like. This being repeated, perma- 
nent dilatation of the capillaries takes place. The dilated 
capillaries are not evident all over the patch. The greater 
part of the patch may present an even redness. The 
border of the patch is ill-defined, and no matter how fiery 
red the color may be the skin feels cool to the touch. This 
is because the congestion is passive on account of a sluggish 
circulation. In some cases, however, there may be but 
little general redness, but only a number of dilated capilla- 
ries. These telangiectases are best seen on the nose. In 
some cases there may develop a congestive seborrhoea or 
even an erythematous eczema, which, yielding to appro- 
priate remedies, leaves behind an undoubted rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be almost 
coincident with it. The number of papules and pustules 
may be considerable, and the tubercles large. If so, the 
amount of redness will be great. The peculiar feature of the 
pustules is their superficiality. They are usually quite 
small, say of pinhead-size, and when pricked give exit to but 
a small drop of thin pus. The tubercles are enlarged or 
clogged sebaceous glands, but all these lesions are but 
secondary to the chronic hyperemia, and not primary, as in 
acne. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyperemia 
leads to an increase of connective tissue, and the nose, tip 
and sides becomes converted into a lobulated mass of tis- 
sue, sometimes so great as to form pendulous tumors hang- 
ing down over the mouth. This last condition is known 
as rhinophyma. The whole nose is of deep-red or purple 
color, and studded over with crater-like openings, leading 



404 DISEASES OF THE SKIN. 

down into the thickened mass. At times ulceration occurs 
in these crypts and causes additional annoyance and de- 
formity from destruction of tissue. 

While in the vast majority of cases the middle third of the 
face alone is affected, in some cases the whole face becomes 
red, and the redness may extend down upon the neck. 
Rosacea is seen at times on the scalp of bald-headed persons 
just above the forehead. 

Etiology. The cause of the disease is probably a vaso- 
motor reflex neurosis. Schwimmer regards it as a tropho- 
neurosis ; Unna as a seborrhoeal eczema. It occurs in 
adult years, most frequently after the twenty-fifth or thir- 
tieth year, though it may occur even at puberty. There is 
no connection between it and acne. While many patients will 
tell you that they had " pimples " when young, as many will 
inform you that they have always had a good complexion 
until the rosacea began. Women are more frequently af- 
fected than men. Digestive disturbances are a very common 
cause of the disease, and the trouble may be located either 
in the stomach, intestines, or accessory digestive organs. 
Drinking of spirits will undoubtedly cause it, on account of 
producing both gastric catarrh and reflex dilatation of the 
facial vessels. The inordinate use of strong tea acts in the 
same way, and probably gives rise to as many cases as does 
alcohol. Exposure to the weather or to extremes of tem- 
perature will cause rosacea without digestive disturbances, 
but when combined with the latter leads on to the most 
brilliant examples of it. Constipation, menstrual derange- 
ments, anaemia, chlorosis, the menopause, each one has been 
noted in connection with rosacea. The use of cosmetics has 
been followed by it. 

Diagnosis. When we meet with a case of redness, with 
or without papules, pustules, or tubercles, that is limited to 
the middle third of the vertical diameter of the face, it is 
probably one of rosacea. It differs from acne in its limited 
area, the superficial character of the pustules, the absence of 
comedones, and the capillary dilatation. Lupus erythema- 
tosus may occur in the same location, but in it we do not 
find the dilated capillaries ; but we do find thickening of 



ROSACEA. 405 

the skin, adherent scales with prolongations from their 
under side, a sharply defined, slightly raised border to the 
patches, and, if the disease has lasted any time, more or less 
delicate cicatricial tissue. In its early stage the diagnosis 
is not always easy. Lupus vulgaris should not confuse us, 
as in rosacea there is an entire absence of the characteristic 
apple-jelly-like tubercles of lupus. The tubercular syphilide 
may resemble rosacea in its second or third stage, but soon 
it undergoes softening and ulceration — processes that do not 
occur in rosacea. Moreover, it is not symmetrical, but 
occurs in the form of groups of tubercles, presents no 
telangiectases, and evidences of other syphilides are usually 
to be found. 

Treatment. In order to successfully treat rosacea, we 
must first endeavor to remove the cause. We must inquire 
as to the condition of the digestive apparatus, the manner in 
which menstruation is performed, exposure to heat and cold, 
and, in fact, ascertain the patient's general condition. Then 
we must address ourselves to the regulation of any deranged 
function. We must stop the use of alcoholics in any form, 
and the ingestion of all hot fluids, such as tea, coffee, and 
soup. All these tend to produce dilatation of the blood- 
vessels of the face and to keep up those conditions we wish 
to remove. The patient's diet should be carefully regu- 
lated, and such things as pastry and sweets cut off, so as to 
make digestion as easy as possible. Medicinally, tincture of 
nux vomica, the mineral acids, or alkalies are to be adminis- 
tered q. r. n. Nux vomica has often seemed to render good ser- 
vice, even without there being marked digestive disturbance. 
Salol is a good remedy in many cases of intestinal fermen- 
tation. Ergot or ergotin proves useful in some cases, either 
with or without uterine disturbances. Ichthyol is com- 
mended by Unna. The ammonio-sulphate is the prepara- 
tion to use, and it is best given in capsules to cover the 
taste. The dose is three drops two or three times a day. 

The local treatment is important in hastening a cure, but 
is not of itself curative in well-marked cases of reflex rosacea. 
The patient must be instructed to protect the skin from the 
action of wind and weather, by either applying some oint- 



406 DISEASES OF THE SKIN. 

ment, such as vaseline, or a powder, such as corn-starch, before 
venturing out of doors. Then the face should be bathed in 
hot water every night before going to bed, the water being 
as hot as the skin can stand without burning, and it should 
be sopped on for about ten minutes, freshly heated water 
being added from time to time, so as to maintain a uniform 
temperature. This is beneficial because the primary dilata- 
tion of the vessels is followed by contraction. After the 
bathing the following lotion should be applied : 



R . Zinc, sulphat., \ . . . # „ 

Potass, sulphuret., J ' a 3J > 

Aquae rosae, ad ^ iv ; 100 



M. 



It is, perhaps, as good as any application we can make. 
Van Harlingen gives another good one, as follows : 

R. Sulphur, precipitat., 3j; 6 

Pulv. camphorae, gr. v ; |5 



Pulv. tragacanth., gr. x ; 1 

Aquae rosae, ~| 2 . 1AA 

t • i • r aa 31 I 1^0 
JLiq. calcis, J ^ ' 



M. 



Instead of lotions, sulphur ointment (5J-5J), or the white 
precipitate ointment may be used, or simply powdered sul- 
phur. In obstinate cases Vleminckx's solution may be 
used. It is composed as follows : 



R. Calcis, 3^ v 5 ^ 

Sulphur, sublimat., 3J ; 10 

Aquae destillat., ^ x ; 100 



M. 



Boil together, with constant stirring, until the mixture 
measures six fluidounces, then filter. 

This is to be diluted four or five times at first, and used 
at night only, followed by cold cream in the morning. The 
dilution is to be lessened by degrees. Any of these reme- 
dies may produce a dermatitis, followed by desquamation, 
which is to be desired. For this purpose we may use re- 
sorcin, 10 to 20 per cent, in vaseline, stopping it when the 
skin begins to peel. Hillairet 1 recommends washing the 

1 Prog. Med., 1880, viii. 182. 



ROSACEA. 407 

face in the morning with hot water, followed by a solution 
of oxide of zinc, three or four grains to the ounce, sopped 
on for half an hour. Before going to bed the following is 
to be applied to the face : 



Be . Camphorated alcohol, 8 ad 15 

Sublimated sulphur, 30 

Distilled water, 250 



M. 



After six days this is to be discontinued for a couple of 
days, and then begun again. Ichthyol has been highly ex- 
tolled by Unna and others, as well for external as for inter- 
nal use. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a few 
days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hypertrophic 
tissue. Pustules are quickest removed by the curette, as in 
acne. Dilated vessels are best destroyed by electrolysis 
with the electric needle attached to the negative pole, intro- 
ducing it perpendicularly into the vessel at one or more 
points of its course, and letting it remain for a few seconds 
until the vessel appears as a white line. The method of 
using electrolysis is more fully described under hypertri- 
chosis. It is often necessary to repeat the operation several 
times before the vessel is destroyed. Multiple scarification 
is most useful in reducing red patches. It may be done by 
means of a scalpel, making parallel lines near together and 
through the skin, and then a second series over these ; or a 
multiple scarifying knife, as sold in the shops, may be used 
for the purpose. After scarifying, bleeding should be en- 
couraged for a few moments by the application of hot water. 
Then the surface should be swabbed over with a solution of 
carbolic acid, two drachms to the ounce of glycerin and 
water. This will check the bleeding and constringe the 
vessels, No after-treatment is needed, as a rule. If reac- 
tion tends to go too far, a soothing ointment may be applied. 
The operation should be repeated once every week or two. 



408 DISEASES OF THE SKIN. 

It is astonishing to see how rapidly the redness will be 
reduced in many cases, and this without deformity being 
caused. Multiple scarifications may be employed for the 
reduction of tuberculated masses, but trimming off the super- 
fluous tissues is a more speedy method. 

Pkognosis. In cases of rosacea arising from exposure to 
weather in drivers and sailors, and those following similar 
pursuits, we cannot expect to effect a cure, as the patients 
cannot do the one thing necessary — give up their occupa- 
tions. In most all other cases we can promise great amelio- 
ration of the annoying redness, and in many we can effect a 
cure ; but we had best not attempt to treat a case that will 
not follow our directions as to diet and hygiene. 

Rosee. See Rosacea. 

Rose Rash. See Erythema. 

Roseola. See Erythema roseola. 

Roseola Pityriaca. See Pityriasis rosea. 

Roseola Syphilitica. See Macular syphilide. 

Roseole Squameuse. See Pityriasis rosea. 

Rotheln (Ru 5 t'e 2 ln), or German measles, is a mild conta- 
gious disease that resembles measles, but differs from it in 
the mildness of all its symptoms, in the lighter color of its 
lesions, and in the absence of the crescentic arrangements 
of them. Like measles, it may be mistaken for either an 
erythema or an erythematous syphilide, and its diagnosis is 
along the same lines as is that of measles, which see. It is 
not so blotchy as measles, and the catarrhal symptoms are 
absent or but slight. Swelling of the glands of the neck is 
a symptom that may or may not be present. Febrile move- 
ment is slight. The lesions may take the form of small 
papules, and assume rather a brownish color than a red. 
The eruption is often itchy, and the lesions may occur on 
the mucous membranes. It differs from scarlatina in the 
mildness of all its symptoms, and in the absence of the dif- 
fuse scarlet eruption of the latter disease. 

Rothlauf. See Erysipelas. 

Rupia. See Syphilis. 



SARCOMA. 409 

Salt-rheum. See Eczema. 

Salzfluss. See Eczema. 

Sarcocele of the Egyptians. See Elephantiasis. 

Sarcoma (Sa 3 rk-o r ma 3 ). We are here interested in sar- 
coma of the skin alone. Sarcomas may be primary in the 
skin, but most often they are secondary. They form 
variously sized tumors, but tend to run a malignant course, 
multiplying more or less rapidly, breaking down, affecting 
internal organs by metastasis^ and killing the patient in a 
few months or years. There are three types of sarcoma — 
namely, the round-cell sarcoma, the small-cell sarcoma, and 
the melano or pigment sarcoma. Very commonly sarco- 
mata are of mixed type ; or sarcomata may be divided into 
two varieties — the pigmented and the non-pigmented. 

According to Brocq, 1 who, following Perrin, has made an 
exhaustive study of the disease, primary melanotic sarcoma 
originates frequently from an irritated nsevus, but may occur 
independently. At first it is always single and small. It 
tends to enlarge and attain the size of a nut. In shape it is 
oval or spherical. It is nearly always sessile. Its color is 
dark-blue or black. It is very hard to the touch. It may 
remain stationary for a long time, but in course of time new 
tumors will appear, either about the original one or at dis- 
tant points by means of the lymphatics. Some of the origi- 
nal tumors will disappear, while new ones appear ; some will 
break down and form irregular ulcers whose floors are black 
and uneven, and secreting a thick, melanotic liquid, or a 
little pus, or almost solid black matter. The viscera become 
involved, and death soon occurs. 

A rare form of melanotic sarcoma is described by Hutch- 
inson as melanotic ivhitlow, which at first is a chronic 
onychitis, the border of which looks like a lunar-caustic 
stain. It very gradually develops into a fungating tumor, 
slightly pigmented. The nail is shed, and generalization 
occurs (Crocker). 

Non-pigmented primary sarcoma may be generalized or 

1 These de Paris, 1885. 
18 



410 DISEASES OF THE SKIN. 

localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard oedema, accompanied by tension of the skin, and per- 
haps itching or pricking. It may begin as brownish-red, 
livid, purple, or blue patches, upon which little pinhead-size 
nodules appear, which gradually enlarge. In some cases 
little, infiltrated, isolated, blue or reddish-brown nodes will 
form. Sometimes the first appearance will be a diffused 
cyanotic patch, which later will become a bossy elevated 
patch. When the disease is fully developed the hands and 
feet are thick, deformed, infiltrated, as firm as cartilage, 
brown or blue with a red tint. The skin is glossy, scaly, 
uneven. The nodes maybe raised, pedunculated, or ulcerated. 
Similar lesions are found upon the rest of the body, though 
rarely on the trunk. They may remain stationary, disap- 
pear, fall off, multiply, ulcerate, or, finally, involve the 
mucous membranes, and cause death. 

The localized form develops ordinarily from an irritated 
nsevus, and is most often encountered on the extremities. It 
forms a hard, wrinkled tumor, which may ulcerate. Its 
color is usually that of the normal skin, though it may be 
red. It may not generalize for a long time, or it may do so 
spontaneously, or after an attempt at removal. 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Etiology. We know very little in regard to the etiology 
of sarcoma. It occurs at all ages, some of the most malig- 
nant cases being seen in childhood. Brocq says that the 
localized non-pigmented sarcoma is most frequent in women, 
and that the generalized form is most frequent in robust 
men of forty to sixty years. Piffard gives the ages at 
which they are most prone to occur as before the fifteenth 
and after the forty-fifth year. 

Diagnosis. The diagnosis of sarcoma is generally easy, 
but at times it is difficult. The pigmented forms are 
usually readily recognizable by their color. The non-pig- 
mented single sarcoma may be distinguished from epithe- 
lioma by its feel, which, though firm, lacks that stony hard- 
ness that is characteristic of cancer. Fibromata are not so 






SCABIES. 411 

firm as are sarcomata, are more commonly pedunculated, 
and show no tendency to degenerative changes. 

Treatment. Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcomata, and in the 
melanotic variety, operative interference is usually not only 
not curative, but has often seemed to hasten generalization. 
Kobner and others have used hypodermatic injections of 
arsenic with brilliant results in some cases. Kobner used 
Fowler's solution of half strength, and injected two and a 
half to four drops of it once a day. After three months the 
dose was increased to seven and a half, and then to nine 
drops. Others have tried arsenic without effecting a cure. 
Still it is worthy of trial, as it may cure the disease if it is 
well borne by the patient. 

Prognosis. This is always grave. The course of the dis- 
ease is nearly always from bad to worse, though the fatal 
result may not be reached for many years. Melanotic sar- 
coma is more rapidly fatal than is the ordinary form. 

Satyriasis. See Lepra. 

Scabies (Skab ; i 2 -ez). Synonyms: The Itch; (^V.)Gale; 
(G-er.) Kratze. A contagious disease of the skin, due to its 
invasion by the acarus scabiei, and characterized by exces- 
sive itching, worst at night, and by excoriated lesions, pus- 
tules, and cuniculi upon the anterior face of the wrists, be- 
tween the fingers, on the breasts of women, the penis of 
males, and about the umbilicus of both sexes. 

Symptoms. The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the dis- 
ease. Itching is always present in it. While it may be 
somewhat in abeyance during the day, it is hardly ever ab- 
sent, and at night in bed it is so bad, in susceptible indi- 
viduals, that sleep is well nigh impossible. The itching 
gives rise to scratching, and the scratching to the secondary 
symptoms of the disease — scratched papules and eczematous 
patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he digs into his skin, and sooner or 
later, according to the resistance of his skin, he produces 



412 DISEASES OF THE SKIN. 

pinhead-size excoriations. Later, the irritation continuing, 
eczematous patches result. When he presents himself to 
the physician, the latter will find on examination the evi- 
dences of scratching, and he will notice that the lesions are 
located principally between the fingers, on the anterior sur- 
face of the wrists and somewhat on the forearms, about the 
axillae, upon the breasts about the nipples in women, upon 
the male genital organs, about the umbilicus and lower part of 
the abdomen, and often upon the buttocks of both sexes, and, 
in children especially, upon the anterior surface of the ankles 
and between the toes. In adults, these latter situations are 
not so frequently affected. Closer examination may be re- 
warded by the discovery of the pathognomonic sign of 
scabies — namely, the cxmiculus, or burrow, which is usually 
found most readily on the inner border of the hand, on the 
inside of the fingers, and on the penis. It forms a delicate, 
slightly raised, whitish or grayish, wavy, often bowed, line, 
about one-eighth to one-half an inch in length, and having 
a white speck at one end which marks the place where the 
itch mite is. These are not always to be found ; indeed, in 
most cases they are difficult to find, because they are broken 
up either by the occupation of the individual, by the use of 
soap and water, or by scratching. In people with delicate 
skin the burrowing of the itch mite will set up an inflam- 
matory process, and papules, vesicles, and pustules will form, 
quite independently of the scratching. 

While the regions mentioned are the ones always affected 
in well-marked cases, variations in the extent of the disease 
are observable. In some cases the hands are free, and but 
few lesions are present anywhere. Here, if it is a male, the 
crucial test will be the examination of the privates, where a 
scratch-mark or a burrow will be found almost without fail. 
In other cases, hardly any part of the body will be free from 
excoriations, pustules, or eczematous patches, excepting the 
face, which is affected only exceptionally, and then nearly 
always in children. In these bad cases furuncles and large 
ecthymatous pustules join themselves to the already multi- 
form eruption of scabies. Urticaria is also present in some 
cases, its wheals being interspersed among the other lesions. 



SCABIES. 413 

Should some intercurrent fever arise, the symptoms of scabies 
will subside, to reappear when the fever is past. The so- 
called Norwegian Itch is only a very much aggravated form 
of the disease, on account of the want of personal cleanliness 
of the people. The face in this form may be affected, the 
nails split and shed, and the palms and soles covered with 
thick crusts. 

Etiology. Scabies is due to the irritation set up by the 
acarus scabiei and by the scratching employed to relieve the 
same. The vesicles, papules, or pustules about the burrows 
are due directly to the acarus ; it may be on account of 
some irritating substance secreted by it. The disease is 
contagious, but requires prolonged contact, as by holding of 
hands, or sleeping with an infected person. It is very rare 
for it to be communicated to a physician in examining a 
patient. 

According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after the 
fiftieth year. This, he thinks, is due to the fact that in ad- 
vanced life the epidermis becomes harder and dryer, and 
forms a less suitable habitat for the acarus. Ten years ago 
the disease was not common in this country, but now it is an 
every-day occurrence to meet with new cases in our dispen- 
saries, and not so very infrequent to meet with it in private 
practice. 

Pathology. The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 
sixtieth to one- eightieth of an inch loner, and the male still 
smaller. Its width is about two-thirds of its length. It 
has eight legs — four on each side of its head, to which 
suckers are attached, and four posteriorly, to all of which, in 
the female, bristles are attached ; while in the male the 
inner ones are wanting in bristles, but provided with suckers 
for attaching himself to the female in copulation. On the 
back are a number of short bristles. A glance at the accom- 
panying plates will describe the animal better than words. 

The acarus, having landed on the skin, soon stirs about, 

1 Boston Med. and Surg. Journ., Sept. 23, 1880. 



414 



DISEASES OF THE SKIN. 



and having found a suitable place, it rests on its hind feet, 
takes an oblique position, pierces the skin, and bores a hole, 
into which it forces itself. It lodges in the deeper layers of 
the epidermis, above, and sometimes in the mucous layer. The 
female bores a burrow equidistant between the surface of the 
epidermis and the level of the papillae of the corium. Being 
prevented by the bristles on her back from moving back- 

Fig. 39. 




ward, she moves forward, and lays her eggs. Her duration 
of life is from six weeks to two months, and during this time 
she lays some fifty eggs. These hatch out, reach the sur- 
face of the skin, meet the male, become impregnated, bore 
in their turn into the skin, and so keep up the process. As 
the thinnest parts of the skin are most easily punctured, it 
is just in these parts that we find the lesions most commonly. 
The scratching often extends far beyond the sites of the 



SCABIES. 



415 



burrows. Fournier found that an acarus died in seven 
days when immersed in cold water, in ten days when in 
warm water, and in two to four days in a solution of green 
soap. He denies the commonly accepted view that the 
acarus is a night-prowler, though he allows that it is most 
active at night. 

Fig. 40. 




Diagnosis. The presence of pustules and scratch-marks 
between the fingers, on the anterior face of the wrists, about 
the umbilicus, on the breasts in women or the genitals in 
men, is enough to make the diagnosis of scabies. If a cunic- 
ulus can be found it will be corroborative evidence. Ec- 
zema is more patchy and does not occur in the characteristic 
locations of scabies. Pediculosis vestimentorum presents 
long, parallel scratch-marks instead of the small excoriations 
of scabies, and their characteristic locations are over the 
shoulders, about the girdle, and along the outside of the 









416 



DISEASES OF THE SKIN. 



arms and the inside of the thighs where the seams of the 
clothing come. The itching of scabies is worst at night, 
while that of pediculosis is not so marked. Urticaria is a 




Burrow of scabies with acarus. (After Kaposi.) 

general disease characterized by wheals and shows no tend- 
ency to localize itself in certain regions. Should urticaria 
complicate scabies, the wheals will be disseminated while the 
lesions of scabies will be most marked in their characteristic 
locations. 






SCABIES. 417 

Treatment. If the disease is recognized there is no 
difficulty in curing it, though there are various methods em- 
ployed. Perhaps the oldest and one of the most reliable, 
though not the most rapid a cure," is to have the patient 
take a warm bath with soap and water, scrubbing himself 
thoroughly so as to remove as much of the old epidermis as 
possible. Then he should dry the skin with vigorous fric- 
tion, and rub into every diseased spot ordinary sulphur oint- 
ment. When this is done he can smear the rest of the 
skin with the ointment, put on the same clothes, and go 
about his business. The rubbings Avith the ointment are to 
be repeated morning and night for three days, the patient 
wearing the same underclothing by day, and bed- and night- 
clothing by night. At the end of three days another bath 
is to be taken, the clothing changed, and the patient should 
then present him self for examination. If fresh lesions are found, 
a second course should be taken, which most always will be 
sufficient. An artificial eczema is apt to be set up by the 
sulphur, and as eczema itself itches we must not take the 
continuance of pruritus beyond the second course as evi- 
dence of the scabies not being cured. It is better to stop the 
sulphur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaseline and corn- 
starch. If the itching grows worse instead of better, a third 
course of rubbing must be crone through with. Instead of 

o o o 

plain sulphur ointment we can add balsam of Peru, about 
half a drachm to the ounce, or use the modified Wilkinson's 
ointment, as follows : 

R . Sulph. sublimat.j I 
01. cadini, j 

Crete preparat. 



Sapo viridis, \ 
Adipis, j 



3 iv ; 


20 


•5ijss; 


10 


ij ; 


80 



M. 



This, though a very efficient remedy, forms such a disgust- 
ing-looking mass, and is so irritating that it is fit only for 
public practice, ,5-napthol, in 5 to 10 per cent, strength 
in ointment or oil, is a good remedy, free from the sulphur 
smell, and not so irritating. Kaposi recommends it in the 



following form : 

18* 



418 DISEASES OF THE SKIN. 



/3-naphthol, 


15 parts 


Sapo viridis, 


50 " 


Cretse alb. pulv., 


10 " 


Adipis, 


100 " 



M. 

and Crocker says: "I can speak of it in the highest 
praise." It is well fitted for private practice. McCall An- 
derson extols styrax liquida with a double amount of lard. 
As the itch is very prevalent in Scotland, the Doctor should 
know of what he speaks. 

The treatment in the St. Louis Hopital of Paris is an 
heroic one, but is said to cure in one hour and a half. Ac- 
cording to Fournier the patient is scrubbed violently for 
half an hour with green soap ; then for another half-hour 
the scrubbing is continued while he is in a bath ; then he is 
rubbed with this ointment : 

Helmericli s Ointment. 



R. Potass, carbonat., ,^ss; 15 

Sulphur, sublimat, |[j ; 30 

Adipis, J iv ; 120 



M. 



Now he puts on his clothes without removing the salve, and 
is discharged cured. In private practice Fournier recom- 
mends the use of a good toilet soap for the preliminary rub- 
bings, and then Bourguignon's ointment as follows : 

R . Glycerini, 200 parts 

Gum tragacanth, 5 

Sulph. sublimat., 100 " 

Potass, carb., 35 " 

01. lavandube, 

01. menth pip, -- 1 50 „ M 

Ol. caryopnylli, j 
01. cinnamomi, J 

This is to be followed by a bath and powdering with corn- 
starch. It cannot be used for children, or in extensive 
cases in adults where there is much excoriation. 

For infants and young children, balsam of Peru is about 
the pleasantest application we can make, it being rubbed in 
morning and night, either pure or diluted with sweet oil : 
or a mitigated form of sulphur ointment may be used. 



SCLEREMA NEONATORUM. 419 

Sherwell 1 commends rubbing in dry powdered sulphur 
after a bath. 

In all cases the clothing and bedding must be disinfected — 
washable things by boiling, and cloth clothing by ironing 
with a very hot iron. All affected members of the family 
must be treated at the same time. An irritable condition of 
the cutaneous nerves may last at times long after the scabies 
is cured, and must not be mistaken for a still active itch. 

Prognosis. The prognosis is always good, provided the 
applications are made thoroughly enough. 

Scall or Scalled Head. See Favus. 

Scarlatina (Ska 3 r-la 3 -ti r na 3 ). Scarlet fever is an acute 
contagious eruptive disease, characterized by a quick rise of 
temperature at the beginning, redness of the fauces, a straw- 
berry tongue, and the appearance of a fine punctate scarlet 
rash, which, first appearing on the neck, chest, and flexures 
of the joints, rapidly spreads over the whole body. The 
redness may be even over all, so as to give a boiled-lobster 
appearance to the skin ; or the red points may be distinct, 
although close together. The redness usually disappears on 
pressure. Vesicles may appear. A great deal of constitu- 
tional disturbance and prostration are apt to attend the 
eruption, but convalescence is well established in the second 
week in uncomplicated cases. Abundant desquamation fol- 
lows the subsidence of the eruption, which continues for days 
or weeks. 

Diagnosis. There is often a striking resemblance be- 
tween scarlatina and erythema scarlatiniforme, and some 
other erythemata. (See Erythema.) 

Scherende Flechte. See Tricophytosis capitis. 
Schmeerfluss. See Seborrhcea. 
Schuppenflechte. See Psoriasis. 
Scissura Pilorum. See Atrophia pilorum propria. 
Sclerema. See Scleroderma. 

Sclerema Neonatorum (Skle 2 r-e r -ma 3 ). Synonyms: 
Scleroderma neonatorum ; Induratio telie cellulose ; (Fr.) 

1 N. Y. Med. Journ., 1889, i. 482. 



420 DISEASES OF THE SKIN. 

Algidite progressive, L'endurcissement athrepsique; (G-er.) 
Das Sclerem der Neugeboren. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in 
1877. It may be primary, but most often it is secondary, 
to some exhausting disease, such as pneumonia or intestinal 
catarrh. It may be present at birth, and rarely occurs after 
the first ten days of life. It is characterized by hardness 
of the skin, which generally at first is circumscribed and 
affects the leg. It may be diffuse from the first, and any way 
it soon becomes so, and extends to the lumbar region, back, 
chest, and so all over the body, becoming universal by the 
fourth day. It may begin on the face, and it may stop be- 
fore becoming universal. It may be but slightly developed 
on the chest. At first the skin is pale and waxy ; later, it 
becomes livid and cold, and the child looks as if frozen. 
The skin becomes attached to the underlying parts, smooth, 
tense, and does not pit on pressure. Movement is impos- 
sible for the child, and the body may be raised without 
moving a joint. When the face is affected, it is impossible 
for the child to nurse. Its respirations are greatly reduced 
in number, its pulse falls to sixty a minute, its breath is 
cool, and it dies within a week. The primary congenital 
cases are either stillborn or die in one or two days. 

Etiology. The cause of the disease is obscure. It is 
seen almost exclusively in foundling asylums and among 
the very poor. It is, therefore, a disease of depressed 
vitality. Langer 1 regards it as the result of solidification of 
the fat, which in infants contains 31 per cent, of palmatin 
and stearin, that of adults containing 10 per cent. The fat 
in infants, he says, is nearly all concentrated in the subcu- 
taneous tissues, where it is five times as thick relatively as it 
is in adults. Naturally, an infant's temperature is higher 
than an adult's, and, if it is lowered by any depressing cause, 
the fat may solidify. Solidification may take place also 
under the action of cold, or by oxidation, as in fevers, with- 
drawing some of the constituents of the fat. Parrot regards 

1 Wien. med. Presse, 1881, xxii. 1375. 



SCLERODERMA. 421 

the disease as one of desiccation from the drain of a diarrhoea, 
or the like. 

Diagnosis. Sclerema neonatorum is differentiated from 
oedema neonatorum by being more general in its distribu- 
tion, by the skin being harder and more tense, and not 
pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 
the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. The course of the disease is almost inevi- 
tably toward a fatal termination, and little more can be done 
than to keep the little body as warm as possible, to rub in 
oil, and to administer concentrated nourishment and stimu- 
lants. Money 1 reported a case in 1889 that was cured in 
six weeks by mercurial inunctions. There was no history 
of syphilis in the case. 

Scleriasis. See Scleroderma. 

Sclerodactylie. See Scleroderma. 

Scleroderma (SkleVo-du^nn'a 3 ). Synonyms: Sclerema 
seu Scleroma adultorum ; Scleriasis ; Dermato-sclerosis ; 
Chorionitis ; Sclerostenosis ; (Fr.) Sclereme des adultes, 
Sclerodermic; (Ger.) Hautsclerem ; Hide-bound disease. 

A subacute or chronic disease, characterized bv the skin 
being hard and rigid. 

Symptoms. The name of this disease indicates the most 
peculiar feature of it — that is, hardness of the skin. It may 
come on without apparent cause, the patient first noticing 
the stiffness of the skin ; or it may follow exposure to damp- 
ness and cold, and be preceded by pains of rheumatic nature. 
It may begin in any part of the skin, but has a preference 
for the upper half of the body. It is usually symmetrical, 
though it may be more pronounced on one side than on the 
other. Having begun, it spreads, it may be very slowly, or 
it may be so rapidly as soon to involve large areas of the 
body. It often runs a capricious course, growing better and 
worse, and leaving sound areas in the midst of the diseased 

1 Lancet, 1889, i. 52(i. 



422 DISEASES OF THE SKIN. 

parts. There may be one patch, or a number of them, and 
the patches assume many shapes, though most commonly 
they are elongated, running lengthwise of the limb. There 
are two varieties of the disease : 1. The infiltrating form. 
In this there is a good deal of infiltration of the skin, which 
is hard, cannot be pinched up, does not pit on pressure, and 
is attached to the deeper structures. The appearance given 
to the affected part is cadaveric. In some cases there may 
be hard oedema. The affected part is usually on the level 
of the surrounding parts, though it may be slightly raised. 
The infiltration merges gradually into the neighboring parts, 
its border being ill-defined and more readily felt than seen. 
The natural folds of the skin are obliterated, ertyhema may 
be present at first, and telangiectases are frequently ob- 
served upon the surface. Not infrequently the patch has a 
lilac border. The color of the skin is paler than that of the 
normal integument, and in some places it may be that of 
iovry. Some scaling may be present, or pigmentation of a 
mottled or diffused character may give the patch a fawn to 
black color. Owing to the stiffness of the skin, the move- 
ment of the joints is interfered with, a state of pseudo-anky- 
losis being established. If the face is affected it loses its 
expression, and the features become immobile. The eyelids 
may escape for some time, but if the disease passes on to the 
atrophic stage, soon to be mentioned, the eyes become wide 
open, and cannot be closed. If the chest is much affected, 
respiration is interfered with. The temperature of the skin 
is usually lowered one or two degrees. It may be normal, 
or somewhat elevated. Sensibility may be increased, nor- 
mal, or decreased. Pruritus is at times annoying. The 
secretions of the skin are lessened with the increase of the 
disease. 

The disease may invade all the mucous membranes. 

To this form the second or atrophic form may succeed 
after months or years. Crocker thinks that it is probable 
that atrophy follows the (Edematous infiltration only. When 
atrophy begins it is progressive, and the skin becomes dry, 
wrinkled, parchment-like. It is most often the upper part 
of the body that is affected — the face and arms. Continu- 



SCLERODERMA. 423 

ous contraction of the skin produces an atrophy of the 
muscles under it, so that finally nothing remains of the 
original structures but the skin and bones, and the joints 
are ankylosed. The face being affected, we will find a 
corpse-like expression, wide-open eyes with ulcerated 
corneas, shrunken gums with loosened and falling teeth. 
The limbs being affected, slight injuries will produce ulcera- 
tions over bony prominences, and the limbs will be semi- 
flexed. The sclerodactylie of Ball is scleroderma of the 
atrophic variety, affecting the arm and causing marked 
atrophy, loosening the joints, and distorting the hands, " so 
that the third and fourth fingers are curled up into the hand, 
the first and second are bent at the first phalangeal joint, 
while the thumb phalanges are over-distended." (Crocker ) 

The general health remains unaffected, often for years ; 
but should the disease be very pronounced, at last a maras- 
mic condition develops and death occurs. Apart from the 
pruritus and feeling of stiffness, we may have no subjective 
sensation, excepting that pain on pressure is exquisite. At 
times burning is complained of. The disease, when of the 
infiltrated variety, tends to a slow and interrupted course 
toward recovery. In the atrophic variety recovery may 
take place. Of course, the atrophied skin will never regain 
its natural texture, but the disease may cease to spread and 
increase. At best, its subject is but a sorry specimen. 

Children may have scleroderma, the youngest reported 
case being thirteen months. In them the disease is said to 
run a more rapid course, both in development and recovery, 
than it does in the adult. Vidal 1 describes a form of sclero- 
derma following a lesion of the skin, such as an eczema, 
which gives rise to a lymphangitis, and is usually met with 
on the leg. 

Etiology. Women are far more often the victims of 
scleroderma than are men — three to one. It is most com- 
mon in young and middle-aged adults. Apart from this, 
we are in uncertainty as to the true cause, though rheu- 
matism, gout, exposure to cold and heat, bad hygiene and 

1 Gaz. des H6p. ; 1878, li. 939. 



424 DISEASES OF THE SKIN. 

poor food, and neurotic influences have each been found in 
apparent causative relation to the disease. 

Diagnosis. There is no other disease of the skin with 
which scleroderma could well be confounded, excepting 
sclerema or oedema neonatorum, morphoea, or cancer en 
cuirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. Morphoea 
is a localized scleroderma, and the diagnosis is therefore 
unimportant. Cancer en cuirasse is more rapidly fatal in 
its course, is at first or soon marked by subcutaneous nodules 
that tend to break down and ulcerate, and is accompanied 
by lancinating pain. 

Treatment. It is doubtful if treatment is ever directly 
of avail. At best, it is unsatisfactory. A general symp- 
tomatic treatment with tonics, good diet, and maintenance 
of the bodily heat is indicated. Galvanism, inunctions of 
the skin with oil, and massage may be tried. West 1 has re- 
ported amelioration in one case by the external use of 
chaulmoogra and olive oil Graham 2 advises the use of 
anti-rheumatic remedies. 

Prognosis. While recovery may take place, it is uncer- 
tain as to its occurrence. Death may result. In children 
the prognosis is more favorable. 

Scleroderma Neonatorum. See Sclerema neonatorum. 

Scleroma Adultorum. See Scleroderma, 

Sclerostenosis. See Scleroderma. 

Scrofulide Boutoneuse Benigne. See Prurigo. 

Scrofulide Crustacee Ulcereuse. See Tuberculosis cutis. 

Scrofulide Erythemateuse. See Lupus erythematosus. 

Scrofulide Tuberculeuse. See Lupus vulgaris. 

Scrofuloderma (Sknrf-u^l-o-du^m'-a 3 ). Modern pathol- 
ogy has led, or is leading, us to use the term tubercular as 
synonymous with scrofula, and a number of dermatoses that 
were for many years regarded by authorities as scrofulo- 



1 Trans. Path. Soc. Lond., 1883, xvi. 2o± 

2 Journ. Cutan and Gen.-urin. Dis , 1886, iv. 332. 



SCROFULODERMA. 425 

dermata have been proven to be due to the bacillus tubercu- 
losis. The most brilliant example of this is lupus vulgaris. 
Many of the scrofulides of the French have been shown by 
more careful observation to belong to various other well- 
recognized forms of skin disease. The marks of a scrofulous 
affection are, according to Bazin : 1. The involvement of 
the deeper layers of the skin; 2. The sharply circumscribed 
character of the lesions ; 3. The absence of pain ; 4. Hyper- 
trophy followed by atrophy of the affected parts ; 5. The 
reddish violaceous or livid color of the lesions ; and, 6. In- 
delible cicatrices left by the same. 

In the present condition of our knowledge of the subject, 
and in a book of this sort, it is impossible to do more than 
to place here a few affections of the skin that do not fit in 
under other well-established diseases, while premising our 
remarks by saying that they are either really instances of 
cutaneous tuberculosis, or will eventually be taken out of 
their present position as scrofulodermata. In all of them 
we have, at the same time, that general make-up of the indi- 
vidual that long has been recognized as scrofulous. The 
patients are mostly young subjects, flabby of flesh, with 
pasty or doughy complexions, thick upper lips, perhaps with 
clubbed fingers, a marked tendency to chronic catarrhal in- 
flammations of all the mucous membranes, chains of enlarged 
glands in the neck, and perhaps with some old or present 
bone lesions. They are usually dull and apathetic, and are 
prone to die with tubercular lung diseases. 

The most common scrofuloderm is that resulting from a sup- 
purating caseous gland, usually of the neck — the scrofulous 
ulcer. The gland, before it breaks down, implicates the skin 
over it, and it becomes of violaceous or livid color, attached to 
the underlying parts. By and by, the skin gives way at 
one or several points ; the sanious, unhealthy pus escapes 
through the openings ; these enlarge, coalesce with others, 
and so form the characteristic ulcer. This has undermined 
edges ; is of irregular shape ; its base is covered with flabby 
granulations ; it discharges a thin, sanious pus ; shows little 
tendency to crusting ; is almost painless, and heals very 
slowly, leaving a puckered, disfiguring scar. This same 



426 DISEASES OF THE SKIN. 

form of ulcer may originate from what is called a scrofulous 
gumma, a subcutaneous tubercle independent of the glands, 
that slowly enlarges to a soft tumor, breaks down, and 
ulcerates. These tumors frequently occur on the limbs, and 
the bones may be involved in the destructive processes 
set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
" large, rounded, ovalish, or irregularly shaped, yellowish, 
flat pustules, with a deep-red or violaceous areola." This 
begins to crust in the centre, and the crust is usually flat 
and scanty, brownish and adherent. Underneath it is an 
ulcer with the characters and course of those just described. 
There may be one, two, or more lesions. The small pus- 
tular scrofuloderm " consists in the formation of pinhead 
and small split-pea-sized, disseminated, yellowish, flat pus- 
tules, with usually a raised, violaceous areola." These 
crust over with depressed yellowish or gray adherent crusts, 
which, w r hen removed, or when they fall off, leave depressed, 
punched-out scars resembling variola. Their course is very 
chronic and painless. They occur upon the face and ex- 
tremities of strumous individuals. 

Etiology. The causes of these scrofulodermata are 
those of the strumous state, and need not be gone into here. 
They are most commonly met with in early life. 

Diagnosis. The scrofulous ulcer differs from that of 
lupus vulgaris by an entire absence of the characteristic 
lupus tubercles, and by its history of beginning in a caseous 
gland. Moreover, in lupus we do not have, as a rule, the 
pronounced strumous condition that we have in the scrofulo- 
derm. The pustular scrofuloderms sometimes resemble 
syphilis, but there is an absence of other signs of syphilis, 
and the presence of the strumous state. Moreover, a pus- 
tular syphilide is generally far more disseminated than is 
the scrofuloderm ; its course is far more acute, it yields more 
readily to treatment, and leaves a smoother, less disfiguring 
scar. 

Treatment. The treatment of the ulcers, as well as the 



SEBACEOUS CYST. 427 

softening glands, is upon surgical principles. The regula- 
tion of the diet and hygiene of the patient, and the adminis- 
tration of cod-liver oil, iron, the compound syrup of the 
hypophosphites, or other tonic, is the most essential part of 
the medicinal treatment. Locally, to the pustular scrofulo- 
derms we may apply iodoform ointment, aristol, or other 
antiseptic powder, or mercurial ointments or lotions. Crocker 
speaks well of chaulmoogra oil emulsion in the dose of ten 
to thirty minims, combined with its external use as an oint- 
ment in the strength of one part to three. 

Scrofuloderma Verrucosum. See Tuberculosis verrucosa 
cutis. 

Scurvy. See Purpura. 

Sebaceous Cyst. Synonvms : Atheroma ; Steatoma ; 
Wen. 

These innocuous little tumors may occur anywhere on the 
body, but are most common on the scalp, face, neck, and 
back. They vary in size from a millet-seed to an orange. 
They may be rounded, flattened, or hemispherical. The 
skin over them may be of normal color, pale on account of 
pressure, or red if the cyst becomes inflamed. They may 
be elastic and doughy to the touch, or firm, or soft, accord- 
ing to the condition of their contents, which may be fluid 
and honey-like, or more cheesy. They tend to grow slowly, 
and give no trouble except by the deformity they cause. In 
exceptional cases they may become inflamed and ulcerate. 
The hair is usually absent over them when they occur on 
the scalp. Cysts of similar nature may be found in loca- 
tions where there are no sebaceous glands, and even under 
the mucous membranes. These are called dermoid cysts, 
and are supposed to be left over from fcetal life. They fre- 
quently contain hair and teeth. 

Etiology. Most cysts are due to distention of a seba- 
ceous gland. The origin of dermoid cysts is undetermined. 
Indeed, considerable uncertainty surrounds the pathology of 
all of them. 

Diagnosis. They must be distinguished from fatty 
tumors and gummata. Fatty tumors are firmer and more 



428 DISEASES OF THE SKIN. 

doughy than cysts, are more often lobulated, occur but 
seldom on the scalp, and are rarely multiple. Gummata 
are more rapid in their growth, attached to the skin, and 
tend to break down and ulcerate. 

Treatment. Complete excision of the tumor, taking 
particular care to remove the whole sac, is the only treat- 
ment to be considered. 

Seborrhagia. See Seborrhoea. 

Seborrhcea (Se 2 b-o 2 r-reV). Synonyms : Stearrhcea, 
Steatorrhea, Seborrhagia, Fluxus sebaceus, Acne sebacea, 
Pityriasis, Ichthyosis sebacea, Tinea amiantacea seu asbes- 
tina, Eczema seborrhoicum, Lichen circinatus ; (Fr.) Acne 
sebacee, Acn6 fluente ; (Ger.) Schmeerfluss, Gneis ; (Ital.) 
Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may be 
of too fluid or too thick consistence, and forms either an 
oily coating or greasy crusts on the skin. 

Symptoms. Seborrhoea is a functional disease of the 
sebaceous glands, which assumes two forms depending upon 
the quality of the products of the glands. Normally these 
glands secrete only sufficient oil to keep the skin soft and 
supple. This normal oil is not visible to the naked eye. 
Under certain imperfectly understood conditions, the glands 
secrete a too fluid and abundant oil that is readily seen as 
an oleaginous coating of the skin. This form of seborrhoea 
is called seborrhoea oleosa. Under certain other equally 
imperfectly understood conditions, the secretion of these 
glands is not only too abundant, but also too consistent. 
Then the sebaceous matter cakes upon the skin in the form 
of more or less thick plates or masses, and we have the con- 
dition known as seborrhcea sicca 

The most common locations of seborrhoea are, naturally, 
those regions where the sebaceous glands are the largest or 
most numerous, namely : the scalp, the chest, the inter- 
scapular region, and the face. 

Seborrhcea oleosa, wdiile it may occupy any or all of these 
regions, is usually subjected to us for treatment only when 



SEBORRHEA. 429 

it occurs upon the face. Here it is seen most often on the 
nose, where it forms a greasy coating. At times this is so 
slight as to be felt rather than seen, imparting a slippery 
sensation to the finger. At other times it is so abundant 
that it can be seen at a distance as drops or beads of oil, 
and when it is removed with a cloth or blotting-paper it 
leaves an oily stain upon it. When it is wiped off it at once 
re-forms. As the greasy skin catches the dust the face is apt 
to look dirty. At times the skin of the nose may be hyper- 
emia The forehead is, likewise, a not uncommon site for 
this form of seborrhoea. It may occur on the scalp, but 
attracts notice only when the patient is bald. Upon the 
nose it may occur as the only disease of the skin. Upon 
the forehead it is a not unusual accompaniment of acne. 
Acne and comedones may complicate the disease in any 
location. 

Seborrhoea sicca occurs with much greater frequency than 
does the oily form of the disease. We are called upon to 
remove it from all the regions already mentioned as the 
locations for the manifestations of seborrhoea. It most 
usually appears in the form of yellowish or grayish fatty 
plates or masses, which when taken and rubbed between the 
fingers impart a greasy feel. Upon the scalp it constitutes 
one form of dandruff. Here it may be general, involving 
the whole scalp, or it may locate itself in certain places in a 
more pronounced way than in others. The hair is dry, and 
after a time, the seborrhoea continuing, it begins to fall, and 
at last baldness is established. 

In this form of seborrhoea it is the hairy regions that are 
especially affected, and we find it in the eyebrows, bearded 
portions of the face, and the hairy portions of the chest. 
The axillae and pubes are rarely affected. In all these 
places it presents similar appearances, yellowish or grayish 
fatty plates. Upon the chest it is not uncommon to see 
the fatty matter in little heaps, piled up as it were about the 
mouths of the hair follicles. Close observation will show 
that the follicle mouths are wider open than they should be. 
As in the oily form the skin feels greasy, and acne and come- 
dones are present. The interscapular region is frequently 



430 DISEASES OF THE SKIN". 

affected, and both here and on the chest the disease often takes 
the form of round or irregularly shaped patches which look as 
if they were covered with a brownish-yellow varnish. 

Aside from the appearance of the fatty crusts and a slight 
amount of itching when the patient is warm, this form gives 
rise to no symptoms. When the crusts are removed the 
underlying skin is of normal appearance. It may be 
slightly paler than it should be, but it is never moist. 
What the patient complains most about is that the scales 
from the crusts, becoming loosened fall upon the clothing and 
make it look as if powdered. If the patient happens to be 
bald he does not find the yellowish fatty crusts upon his bald 
head at all ornamental. But the most serious aspect of the 
case is that if the disease is not cured it is very sure to cause 
the hair to fall, especially if the patient is at all predisposed 
to baldness. 

There is a second variety of seborrhoea sicca, in which a 
varying amount of dermatitis is added to the seborrhoea. 
This variety is the lichen circinatus of the English, and the 
seborrhoea corporis of Duhring. Then there will be a rim 
of redness about the fatty crust, und when the crust is 
removed from the skin, the underlying part will be seen to 
be red. In this variety there will be far more decided itch- 
ing and burning than in the preceding variety. It is to be 
noted that although the skin is red, it is always dry and 
never infiltrated, in these respects differing from eczema. 
Upon the chest and back the eruption will assume the form 
of circular patches covered by a yellowish or brownish 
crust, the peripheries being of a more or less bright red. 
Or the surface of the patch will be smooth and appear as if 
it had been varnished over with a brownish-yellow varnish. 
Sometimes two or more patches will run together, and then 
we will find an irregularly shaped patch with a scalloped 
border. These patches will assume large dimensions in some 
cases. There may be one or several patches upon the chest 
or back. Instead of these circular patches, ring-shaped 
patches may form. These tend to spread at the circumfer- 
ence, and to clear in the centre. When two rings meet at 
their peripheries the points of contact give way, and we have 



SEBORRHCEA. 431 

irregularly shaped figures with a scalloped outline. At 
times the rings themselves are not complete, and we meet 
with a number of broken rings and gyrate lines scattered 
over the chest or back. Owir>g to the constant rubbing by 
the clothing to which the chest and back are exposed in all 
people, and to the influence of soap and water in those who 
indulge in the daily bath, the crusts are frequently missing 
from the circles and rings. Then the eruption consists of 
red rings and circular patches, which on close inspection are 
seen to be made up of a number of red points. These points 
are the open mouths of the sebaceous glands surrounded 
by a zone of inflammatory redness. This variety of sebor- 
rhoea sicca is met with also on the scalp. Indeed it is never 
present on the trunk without at the same time being upon 
the head. Upon the scalp it is seen best in those who are 
bald. We find at times the same rings and circles that 
we have learned to recognize upon the chest, but it is rather 
more common for the disease to assume the form of a more 
diffused patch involving a large part of the scalp, with a 
zone of redness about the edges. When the disease is pres- 
ent in this pronounced form upon the scalp it is very prone to 
pass over onto the adjacent parts of the forehead and thus to 
form as it were a corona seborrhoicum. This corona will 
take the form of a yellowish or brownish crust with a red- 
bounding line. The disease may in like manner pass over 
onto the adjacent parts of the skin of the neck. 

Upon the nose this variety of seborrhoea forms a yellow 
plate with a red line about it. At times this plate may be 
extensive enough to cover the whole nose. More frequently 
the disease is limited to the furrow behind the alee nasi, and 
then assumes the form of some fatty scales upon a good deal 
of underlying redness. The eyebrows and bearded portions 
of the face are also quite commonly affected, but rather as a 
diffused redness combined with a branny scaling, than as a 
solid plate surrounded by a red line. 

Besides the regions already mentioned as the usual loca- 
tions of seborrhoea, we also meet with the disease upon the ears 
(in the tragus and behind the ears), and in the anal fold. 
The scalp is, however, by far the most frequent location of 



432 DISEASES OF THE SKIN". 

the disease, and here it may exist alone for years. When- 
ever it exists elsewhere, it is sure to be found at the same 
time upon the head. 

In infants the disease is very common, taking the form of 
thick crusts upon the scalp, that are often of a dirty-gray 
color. These give the careful mother a good deal of annoy- 
ance, she being in great dread lest someone should think 
that she is not careful to keep the precious baby clean. This 
form of the disease is usually the remains of the vernix 
caseosa. 

Pityriasis capitis used to be considered a form of sebor- 
rhea. It should be considered rather as a scaling off of the 
upper part of the corneous layer of the skin. 

Etiology. The usual etiological factors of seborrhea, as 
given in the text-books, are debility, chlorosis, constipation, 
and a number of other things, indicating that the condition 
of the patient is below par. Of course, the ability of these 
to cause dandruff is questioned. But that they are quite 
capable of aggravating the disease, I have no doubt. The 
disease affects all classes and conditions of men, all ages, 
and both sexes. 

There are many things that seem to indicate a contagious 
element in the etiology of the disease. Cases have been 
reported, in which a husband or wife has contracted dan- 
druff after marriage, he or she having been, before, free of the 
same. Then, those experiments of Lassar and Bishop point 
in the same direction. They took the scales from the head 
of a student who was losing his hair, and, having made a 
pomade of them with vaseline, rubbed the same into the 
back of a guinea-pig, and the pig became bald. Up to two 
years ago we accepted without question the theory that 
seborrhea was a functional disease of the sebaceous glands. 
But Unna would have us believe that there is no such 
disease as seborrhea. He teaches that the process is inflam- 
matory from the start, and that the oil that fills the epithe- 
lial scales comes not from the sebaceous glands but from the 
sweat glands. What we have called seborrhea sicca he 
would have us call, for the present at least, seborrheal eczema. 
(See Eczema seborrhoicum.) 



SEBOREHGEA. 433 

In support of his thesis he presents us with microscopical 
studies and certain arguments. His work has been re- 
viewed by other competent pathologists, and I believe that 
many of his observations have been substantiated by their 
findings. His proposition that the sebaceous glands are not 
responsible for seborrhcea has not been accepted generally. 
It has long been known that, to a seborrhcea, a dermatitis 
may be added, and that this, under various influences, may 
become an eczema. But this is a very different thing to 
saying that seborrhoea does not exist and that all those cases 
that we have been accustomed to call seborrhoea are but a 
variety of eczema. 

What we call seborrhoea oleosa, Unna believes to be 
nothing more than a hyperidrosis, to which he gives the 
name of hyperidrosis oleosa. This view he must take of 
necessity, on account of his theory of the office of the sweat 
glands. 

This is an age of microorganisms, and all diseases are 
traced to a parasitic origin. And so it is affirmed that the 
disease under discussion is contagious, and due to a micro- 
organism. Up to the present time, though a number of 
parasites have been found on the scalp, there is no one that 
can hold its place as the cause of the disease. Brooke, of 
Manchester, would have us believe that, to the unknown 
parasite of seborrhoea without dermatitis, another equally 
unknown parasite adds itself, to produce the dermatitis and 
the ring formation. 

Diagnosis. The diagnosis of seborrhoea is usually easy. 
It is to be recognized by the presence of fatty grayish or 
yellowish plates or crusts, seated either upon a normal or 
slightly reddened skin. These crusts or plates differ from 
those met with in eczema, in being more readily removed, 
and imparting to the finger a greasy feel. Moreover, the 
crusts of eczema are of a more solid consistence, being formed 
by the drying of an almost mucilaginous discharge upon 
the skin. When eczema occurs upon the head the exuda- 
tion glues the hairs together. In seborrhoea, the hairs are 
not glued together, but are dry and powdery. In eczema, 
there is more or less itching at all times, while in seborrhoea, 

19 



434 DISEASES OF THE SKIN". 

the itching comes on most generally when the head is hot, 
as from artificial lights, sweating and the like. In eczema, 
there is moisture, or a strong tendency thereto. In sebor- 
rhcea, moisture is never seen. 

Psoriasis is another disease with which seborrhoea is apt 
to be confounded, as it too, occurs in the form of powdery 
scales and crusts upon the scalp. If a case presents itself 
with these conditions upon the head alone, you may be very 
sure that you have to do with a case of seborrhoea, as psoria- 
sis never exists upon that region alone. Seborrhoea usually 
occurs diffusely, while psoriasis occurs in the form of circum- 
scribed patches. The crusts of seborrhoea are yellowish or 
grayish, while those of psoriasis are of a silvery hue. In 
some cases, however, seborrhoea will occur in circumscribed 
patches, and the crusts of psoriasis may be of a grayish hue. 

When seborrhoea occurs upon the chest and back in the 
form of rings with scaly centres, we have before us a more 
difficult problem in diagnosis. Now we must decide whether 
we have to do with a seborrhoea, a ringworm, or a pityriasis 
rosea. The resemblance to ringworm is often very striking, 
but ringworm does not, as a rule, occur in so diffuse a 
manner. If, at the same time, with the lesion on the chest 
we find other lesions on the back between the shoulder 
blades, we may be quite sure that the case is one of sebor- 
rhoea. Happily in any doubtful case we have a sure resort 
in the microscope. If the case be one of ringworm we will 
surely find the tricophyton. Upon examining the scalp, if 
the disease be seborrhoea, we will surely find plain evidence 
of it there. There should be no difficulty in recognizing 
the presence of a ringworm on the scalp. 

In the differential diagnosis from pityriasis rosea, we are 
deprived of the kindly aid of the microscope. Here, too, 
the occurrence of seborrhoea on the scalp will aid us in our 
decision. Moreover pityriasis rosea is generally more diffused 
over the trunk than is seborrhoea, and occurs also on the 
arms and abdomen. By close inspection we may trace the 
development of the disease from its beginning as a small red 
spot through its successive growth into the typical oval or 
annular patch with its withered parchment or chamois 






SEBORRHEA. 435 

leather-like looking centre. It is scaly, never crusted. In 
some cases, however, the diagnosis will remain somewhat 
doubtful. 

Treatment. The treatment of seborrhcea is simple. It 
is somewhat in favor of the parasitic theory of the origin of 
the disease that the drugs that are most efficacious in its 
cure are active antiparisitics. In my hands by far the 
most satisfactory remedy has been sulphur. After the 
removal of the crusts by means of any oil or grease (this 
should be done the first thing whatever remedy is chosen), 
the sulphur is to be applied in the strength of a drachm to 
the ounce, either suspended in sweet oil, cotton-seed oil, or 
vaseline. It should be well rubbed into the scalp, and the 
application repeated every night for one week. It is well 
to advise the patient to wrap his head up in a towel, or to 
wear a night cap. After one week's use of the sulphur the 
head is to be washed with soap and water, and the oil, or 
salve, immediately reapplied. During the second week it 
will be sufficient to make the application every other night. 
Thus the treatment is to be continued, the number of appli- 
cations being reduced until they are made but once a week. 
By this time the disease will be cured. The patient is to 
be cautioned that relapses are likely to occur, and therefore 
it will be best for him to keep a supply of his oil, or salve, 
on hand so as to attack the trouble as soon as it shows 
itself. 

The objections to sulphur are two : it has a slight odor, 
and it leaves a slight yellow powder on the scalp. The first 
objection is of not much importance and may be overcome 
by adding a scent to the oil. The second is lessened by 
cautioning the patient not to use the application too freely 
and by having him wash the head. 

If your patient is a woman, in private practice you will 
find that the ointment recommended by my distinguished 
friend, Dr. Bronson, will be a very elegant as w T ell as effi- 
cient substitute for the sulphur. It is 



R. Hydrarg. amnion., 9j~*j 5-10 

Hydrarg. chlor. mitis, By _ iv 10-20 

Vaselini, |j 100 



M. 






436 DISEASES OF THE SKIN. 



This is to be used in the same manner as the sulphur 
ointment. 

While one or the other of these will bring the case to a 
happy issue, it is well to have a variety of means at com- 
mand. You will find benefit by using salicylic acid in 
castor oil, three per cent, strength : resorcin in oil or vase- 
line in about five per cent, strength ; or a solution of 
hydrate of chloral, a drachm to the ounce; while for a 
soap both for cleansing and stimulation nothing is better 
than the tincture of green soap. If the scalp is peculiarly 
irritable then it is best to use a milder soap, such as Pears's 
glycerin soap. 

The treatment of seborrhoea of the body and face is 
upon the same lines as that for the head, only that on the 
body we can use an ointment instead of an oil. 

For the seborrhoea of children, usually all that is required 
is to keep the scalp well oiled with olive oil. If this does 
not cure, then a mild sulphur ointment with vaseline may 
be used. 

For seborrhoea oleosa, dabbing ether on the part will most 
promptly remove the greasy look. Washing with soap and 
water will act as a stimulant, and powdering with sulphur 
and starch will prove curative. 

In all forms general treatment will be called for if the 
patient is out of tone. General tonic treatment is required 
in nearly all cases of seborrhoea oleosa. 

Under Alopecia furfuracea will be found further directions 
as to the treatment of seborrhoea of the scalp when it has 
led on to baldness. 

Seborrhoea Congestiva. See Lupus erythematosus. 

Seborrhceal Eczema. See Eczema seborrhoicum and 
Seborrhoea. 

Shingles. See Zoster. 

Siderosis (Si 2 d-e 2 r-o'si 2 s). A defacement of the skin due 
to the entrance into it of small particles of iron or steel, pro- 
ducing blue-black marks. It is seen in iron-workers. 

Sommersprosse. See Lentigo. 

Sphaceloderma. See Dermatitis gangraenosa. 



sYcosrs. 437 

Spargosis. See Elephantiasis. 

Spedalskhed. See Lepra. 

Spider Cancer. See Telangiectasis. 

Spitze Condylom. See Verruca and Syphilis. 

Stearrhoea. See Seborrhoea. 

Steatorrhoea. See Seborrhoea. 

Steatoma. See Sebaceous cyst. 

Stigmasie. See Stigmata. 

Stigmata. See Haematidrosis. 

Stinkschweiss. See Bromidrosis. 

Stonepock. See Acne. 

Striae et Maculae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Strophulus. See Miliaria. 

Strophulus Albidus. See Milium. 

Strophulus Prurigineux (Hardy). See Prurigo. 

Struma. See Scrofuloderma. 

Sudamina. See Miliaria. 

Sudatoria. See Hyperidrosis. 

Sudor TJrinosus. See Uridrosis. 

Sueurs Colorees. See Chromidrosis. 

Sweating, Excessive. See Hyperidrosis. 

Sycosis (Sik-o'si 2 s). Synonyms : Sycosis non parasitica ; 
Sycosis menti ; Sycosis barbae ; Mentagra ; Acne mentagra ; 
Folliculitis barbae ; Folliculitis pilorum ; Herpes pustulosus 
mentagra ; Lichen menti ; Acne sycosis ; (Fr.) Sycosis non 
parasitaire ; Dartre pustuleuse mentagre ; Adenotrichie ; 
(Ger.) Bartfinne, Bartflechte; Fikosis ; (Eng.) Barber's itch. 

Definition. A chronic follicular and perifollicular 
inflammation of the long hairs, chiefly affecting the bearded 
portions of the face ; characterized by an eruption of papules, 
pustules, and tubercles perforated by hairs ; by the forma- 
tions of infiltrated patches ; and by a greater or less amount 
of crusting. Sometimes the disease is so intense as to form 
abscesses. 



438 DISEASES OF THE SKIN. 

Symptoms. It is only of comparatively recent years that 
this disease has been recognized as a separate entity, and 
it is still regarded by some authorities as merely a form of 
eczema. The disease begins by the formation of a number 
of red inflammatory papules and tubercles which are more 
or less conical, usually raised above the surface of the skin, 
and always perforated by hairs. Their appearance is pre- 
ceded and accompanied by disagreeable local sensations, 
such as pricking, burning, and smarting, and at times by a 
feeling of tension in the part on account of swelling of the 
skin. In acute cases there is considerable redness of the 
skin between the papules, and the inflammation may be so 
intense as to give rise to enlargement of the neighboring 
lymphatic glands. The papules and tubercles vary in size 
from that of a millet seed to that of a pea, and are isolated 
or grouped, not every hair follicle in a diseased part being 
affected by the peri-follicular inflammation. Only in very 
severe outbreaks or in acute exacerbations do the papules 
and tubercles tend to run together and form infiltrated 
patches. 

The papules and tubercles soon change into pustules, 
which preserve the same characteristics of grouping and are 
likewise always pierced by hairs. These pustules, conical 
in shape, and perforated by hairs, are pathognomonic of the 
disease. In old cases they are met with in the infiltrated 
patches arising apparently without the preceding appear- 
ance of papules and tubercles. The pustules show no tend- 
ency to rupture, but the pus accumulates below, swells up 
alongside of the hair, appears upon the surface of the skin, 
and dries into thin crusts. The amount of crusting is never 
very great, far less than in eczema of the beard, and is 
appreciable mainly when the beard is growing. If the in- 
flammation is very intense we may meet with small cutaneous 
abscesses here and there instead of pustules. According to 
A. R. Robinson, the amount of pus production varies with 
the individual attacked, being more rapid and abundant in 
the robust than in the scrofulous ; in acute than in chronic 
cases. 

The hairs, if of any length, are early affected in appearance, 



sycosis. 439 

becoming lustreless. They are first firmly seated in their 
follicles, and when pulled upon give rise to pain, and if 
extracted their root sheaths will appear as clear glassy 
cylinders. Later, as pus forms more abundantly in the peri- 
follicular tissues, and the follicles themselves are involved 
in the process, the hair becomes loosened and easily 
extracted, when its root sheath will be found swollen with 
pus. If the pus production is excessive the hairs will fall of 
themselves or upon the slightest traction. When this occurs 
the hair papillae may be so damaged that no new hairs will 
form. In chronic cases the beard is markedly thinned, 
though permanent loss of hair is the exception. 

The disease may attack any part of the bearded face, and 
may be met with in other hairy regions, as the neck, the 
eyebrows, scalp, axilla, and pubes. But the beard is by far 
most often the site of the disease, the other situations being 
affected in the order in which they are named. Occurring 
in the beard it may be limited to a single region and show 
no tendency to spread. Thus it is met with very frequently 
upon the upper lip alone, or at times upon the chin alone. 
It may attack the whole bearded face in an acute outbreak, 
or it may involve it by extension from a limited area during 
a number of successive outbreaks. In chronic cases it is 
usually symmetrical. The course of the disease is chronic 
and made up of a number of acute exacerbations. If left to 
itself it may produce a good deal of deformity, the tubercles 
and pustules breaking down, ulcerating and leaving cicatri- 
cial tissue and more or less baldness, though this is excep- 
tional. 

A typical case of sycosis presents the following appear- 
ance : upon a single region, two or more regions, or upon 
the whole bearded portion of the face there will appear 
a number of isolated or grouped papules, tubercles and pus- 
tules pierced by hairs. The skin about the lesions is red- 
dened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly the 
eyebrows will be similarly affected, and a blepharitis will be 
present. When the case is watched for a time, marked 






440 DISEASES OF THE SKIN. 

exacerbations will arise often without apparent cause, last 
for a few days, and then the disease will sink into a subacute 
condition. When the disease affects the vibrissa of the 
nose, by extension from the upper lip, the Schneiderian mem- 
brane becomes swollen and exquisitely sensitive. The dis- 
ease tends to run a chronic course, lasting for years. 

Etiology. The etiology of the disease is not settled. 
It is not very common, perhaps one case in three or four 
hundred. It is non-contagious. It is seen in men almost 
exclusively, as we might expect ; and attacks them most 
frequently between the ages of twenty-five and fifty. It 
affects all classes and conditions. 

Eczema is often a forerunner of sycosis, the one process 
passing over into the other. A nasal catarrh is the cause of 
the majority of cases occurring on the upper lip. Shaving 
with a dull razor against a stiff beard is sometimes an exciting 
cause, though those who do not shave are by no means ex- 
empt from the disease. An irritant applied to the skin may 
excite it, such as exposure to intense heat, the dust of a 
workshop, cosmetics, and the like. Exposure to inclement 
weather is regarded by Wilson as the principal cause. One 
of the worst cases I have ever met with was directly trace- 
able to a poultice applied to the face for the relief of a 
neuralgia. Given a hypersemic or irritable condition of the 
skin of the face, arising from any internal or external cause, 
the hairs, especially if they are coarse, may excite the dis- 
ease, acting as irritants when touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed 
the inflammation to irritation of the hair follicle by hairs 
whose diameter was, relatively, too large for their follicles. 
By many the staphylococcus pyogenes is regarded as the 
sole cause. 

Pathology. The disease is primarily a peri-folliculitis, 
the hair follicles being affected secondarily, and after them 
the sebaceous glands. 

Diagnosis. The distinguishing characteristic of sycosis 
is the presence of pustules pierced by hairs. It must be 



SYCOSIS. 



441 



diagnosed from trichophytosis barbae, eczema barbae, the small 
pustular syphiloderm, acne, and lupus. The differential 
diagnosis of sycosis from trichophytosis barbae is as follows : 



Trichophytosis Barbae. 

Begins as a small scaly spot, a 
superficial ringworm, and grad- 
ually involves the deeper parts 
of the hair. 

Has its favorite seat upon the 
chin and the submaxillary re- 
gion ; rarely attacks the upper 
lip. Often symmetrical. 

The eruption consists of tubercles 
and nodules which tend to 
group, and are studded with a 
number of hairs. The inter- 
nodular portions of the skin 
often remain unaffected. 



Sycosis. 

Begins suddenly with an out- 
break of papules which soon 
become pustules, each of which 
at the start involves a hair. 

Its favorite seat is the upper lip, 
and sometimes it alone is in- 
volved. Involves the hairy 
portions of the face more gener- 
ally, and often symmetrical. 

The eruption consists of papules 
and pustules, each of which is 
pierced by a single hair, and 
they show no disposition to 
group. The intervening skin 
is generally reddened, and may 
be difiusedly infiltrated; and 
abscesses may form. 

Is a more superficial inflamma- 
tion. 

Hair diseased secondarily, and 
comes away at first with diffi- 
culty, causing much pain. 
Later is easily removed and its 
root is swollen with pus. 

Subjective symptoms of pricking, 
burning, and tension of the 
part. These are often intense 
and attended with swelling of 
the face. 

Limited in most cases to hairy 
parts of face. No tendency to 
extend on non-hairy parts of 
face or neck. 

No fungus present. 

The course of the disease made 
up of a number of acute out- 
breaks. Liable to relapse. 

The differential diagnosis from eczema of the beard 
cannot be made with so much certitude, and often we must 
remain for a while in doubt as to the true nature of the case. 
At times sycosis is left by a preceding eczema, and we may 
meet with a case in the transition stage when a sure diag- 
nosis would, manifestly, be impossible. A typical case of 
pustular eczema is attended by a far greater amount of 

19* 



Is a deep inflammatory process 
so soon as the hairs become 
affected. 

Hair is diseased primarily, and is 
twisted, split and broken. May 
readily be removed by slight 
traction and without pain. Its 
root is often dry. 

Subjective symptoms slight, may 
be only slight pruritus. 



Patches of ringworm often pre- 
sent on other parts of the body, 
and sometimes the disease ex- 
tends upon the neck or face. 

Hairs and scales loaded with the 
trichophyton fungus. 

Is a progressive disease, and when 
cured not liable to relapse. 



442 DISEASES OF THE SKIN. 

crusting than is sycosis, and the crust is of a more greenish 
or blackish color. Upon removing the crust in eczema a 
moist and oozing surface will be exposed, while in sycosis 
we will do no more than remove the tops from a number of 
pustules. In eczema the pustules break down more readily 
than in sycosis, and they are not so accurately located about 
the hairs. In eczema the whole surface of the skin is in- 
volved, and the process tends to extend upon non-hairy 
parts of the face. While exceptionally eczema is confined 
to the hairy portion of the face, this is always so in sycosis. 
The duration of the disease will at times help us to a diag- 
nosis, sycosis being far more chronic than is eczema. In 
syphilis, when the beard is involved, we will find pustules 
upon other portions of the body, and the history will help 
us to a correct conclusion. Further the pustules or papules 
of syphilis are grouped in circles and segments of circles, are 
of a peculiar color, and their development is painless and 
comparatively slow. Acne is scattered about the whole face, 
and is usually met with in young persons. Comedones are 
present, and its papules, pustules, or tubercles have no defi- 
nite relation to the hair. The course and history of lupus 
are so different from that of sycosis that it is hardly possible 
for them to be confused. In lupus vulgaris we have the 
characteristic brown tubercles which do not contain pus, are 
not confined to the hairy portions of the face, generally begin 
in early life, and tend to ulcerate or to be absorbed and leave 
behind cicatrices. 

Treatment. The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should en- 
deavor to put him in as good a hygienic condition as possi- 
ble. He should be advised against exposing himself to dust 
and wind, and then only with his face powdered or protected 
with ointment, and even against smoking, especially in the 
wind where the smoke blows against the face. The proper 
regulation of the diet is important. Many cases will improve 
if we stop their tea, coffee, hot drinks of all sorts, ale, beer, 



sycosis. 443 

and spirits. If the digestive process seem at all embar- 
rassed it is well to put the patient on a light diet for morn- 
ing and evening, and direct him to take his principal meal 
at noon, eating meat only at that time. Anything that is 
known to him to be indigestible must, of course, be pro- 
hibited. In a word, the diet and hygiene of the patient 
should be regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there is 
much swelling and inflammation, a good dose of blue pill, 
calomel, or some other active cathartic is to be ordered, to 
be followed by an alkaline diuretic. When pustulation is 
active the sulphide of calcium or calx sulphurata will do 
good. Piffard recommends this very highly, giving one- 
tenth of a grain two or three times a day. 

Small doses of calomel, as one- tenth of a grain, three times 
a day, for two or three days at a time, are useful in relieving 
the congestion of the skin. In chronic cases iron, cod-liver 
oil, and other tonics are indicated if there is a state of 
debility. Arsenic is advised in very obstinate cases. If 
indigestion is present we must address our remedies to its 
relief before we give calcium, arsenic, or other remedy for 
the disease proper, and then will probably have no need of 
so-called specifics. 

The local treatment must vary with the condition found, 
whether it be acute or subacute. When the disease attacks 
the upper lip, the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped on the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the use 
of a simple oil, such as olive oil or sweet almond oil ; or if 
the face is shaved, the zinc oxide ointment or cold cream 
may be used ; or better still, Lassar's paste, as follows : 



]&. Amyli, \ __ ... q 

Zinci oxidi, J ' 3 J > 

Vaselini, ad ^j ; 32 



M. 



444 DISEASES OF THE SKIN. 

Powdering the part with corn-starch, or bismuth and talc 
after smearing on a little vaseline, will at times give ease 
and comfort. 

If the process is attended by a good deal of oedema and 
the inflammatory symptoms are severe, warm poultices will 
relieve the disagreeable sensations of the patient and reduce 
the inflammation. In some cases cold starch poultices will 
be better borne. Devergie recommends steaming the inflamed 
parts every second day, and covering the affected parts con- 
stantly with cold, or almost cold, thin flaxseed poultices. 
Even in the early stage, if the inflammatory symptoms are 
not very intense, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing the face with " black wash," followed by zinc oxide 
ointment with a drachm of alcohol or half a drachm of cam- 
phor to the ounce, spread on cloths and bound on; and 
speaks well of the oxide of zinc ointment with fifteen to 
thirty grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 
by the free use of olive oil, or oil of sweet almonds, letting 
it soak in thoroughly over night and washing the part with 
soap and warm water the next morning. If the crusts are 
thick, it is a good plan to tie up the bearded face in a towel 
after anointing it with oil. After the crusts are gotten rid 
of, pull the hairs out of the pustules, and insist upon the 
patient shaving himself every second day. If plenty of warm 
water and soap are used, and a good lather formed, the 
shaving will not be very painful, and it is only the first 
shave that is painful. Epilation of the hair from all the 
pustules and papules is to be continued until they cease to 
form. Shaving is to be continued until some months after 
the skin is apparently well. It is possible to cure a case 
without shaving, but the cure will be more difficult to effect. 
The patient must be made to understand that epilation is 
necessary both for the cure of the affection and the salva- 
tion of the hair. After epilating, the oxide of zinc ointment, 
Lassar's paste, or diachylon ointment is to be used. Sul- 
phur in the form of an ointment, half a drachm to a drachm 



sycosis. 445 

to the ounce, or in powder will sometimes do good, but often 
will prove too irritating. Tilbury Fox recommends the use 
of the following ointment after shaving : 

R. Zinc oxide, 1 aa zi- 4I 

Zinc carbonate, J dJ ' 

Eose ointment, ad ^j ; 32 1 M. 

Instead of an ointment we may use oxide of zinc, one 
drachm to the ounce of linseed or other oil. Shoemaker 
advises the application of equal parts of oleate of mercury 
and olive oil. 

In subacute and chronic cases a more active treatment is 
necessary. Here our aim is not so much to allay inflamma- 
tion as to stimulate the skin. To this end we may use the 
soap and salve treatment of Hebra, which renders such good 
service in chronic cases of eczema. (See page 170.) In 
some cases better results will be attained by the use of dia- 
chylon ointment, or Lassar's paste with ten or fifteen grains 
of salicylic acid to the ounce. In very obstinate cases where 
there is much thickening of the skin, green soap may be kept 
applied to the part like an ointment When sufficient inflam- 
matory reaction is produced, emollient measures, as in the 
acute stage, should be used. 

Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and the 
dressings must be kept continuously in close contact with the 
affected part. Sometimes a sulphur ointment, one-half a 
drachm to two drachms to the ounce ; an ointment of iodide 
of sulphur ; the ointment of the ammoniate (gr. xv-xxx ad 
5j), or the nitrate (3j-ij ad 5j), or the red oxide (gr. v-xv 
ad 5j) of mercury will prove useful. Robinson recommends 
the following ointment : 

Be . Ungt. diachyli (Hebra) \ 
Ungt. zincioxidi, j 

Ungt. hydrarg. ammon., 
Bismuth, subnitrat., 5J ss ; 51 M. 

He has found cod-liver oil the best local application in 
strumous subjects. Veiel, in Ziemssen's Encyclopaedia, 



ijss; 


50 


3HJ; 

3 J ss ; 


5 



aa 


10 




o 


a a 


20| 



446 DISEASES OF THE SKIN. 

advises painting the affected parts twice a day with a two 
per cent, solution of pyrogallol in alcohol, and applying 
during the night. — 

]je . Sulphur, lact. ^ 

Alcohol., >- aa 30 

Aquse rosse, J 

Mucilag. gum. acacise, TTlxx-xxx ; M. 

Hans v. Hebra's plan of treatment is to epilate and shave, 
and then with a stiff brush to rub in once or twice a day 
some of the following ointment : 

R.Ol.fagi, I 
Flor. sulph., J 
Pulv. cretse alb., 
Adipis, \ 

Sapo. viridis, J M 

Cover with flannel. Devergie recommends painting the 
part every four or five days with a solution of nitrate of 
silver, one part in five of water, by weight. 

Behrend has obtained good results by scraping the affected 
parts with the dermal curette and dressing with a simple 
ointment or oil. All abscesses must be opened. In some 
cases the following ointment has given me satisfaction after 
other combinations have failed 

& . Hydrarg. sulph. rubri, 5 

Sulph sublimat. 12 

Adipis, ad 50 

01 bergamot. q. s M. 

To be kept on constantly. 

Solutions of the bichloride of mercury, 1 in 1000 ; or of 
resorcin in alcohol 5 per cent, strength, after shaving, may 
be used . 

Kaposi recommends the following : 

]&. /?-naphthol., 1 

Spt. sapo. viridis, 25 

Alcoholis, 50 
Bals. peruv., 2 

Sulph. loti, 10 M. 

Boric acid, salicylic acid, and numerous other reme- 
dies seem to do good in some cases. To assure against a 



SYPHILIS. 447 

relapse it is necessary to continue shaving and making 
applications to the skin for four or five months after ap- 
parent recovery. 

Prognosis. This is one of the most obstinate of diseases. 
Left to itself, when once under headway it shows no tend- 
ency to get well, and has been known to last twenty or 
thirty years. Even under the most judicious treatment it is 
an obstinate disease, taking weeks or months before a cure 
is effected. Relapses are exceedingly liable to occur, and 
these sometimes show a disposition to recur at certain sea- 
sons. Unless the hair is carefully withdrawn from the 
inflamed follicles permanent baldness may be caused. But 
the disease is not dangerous to life, and it is curable. 

Sycosis Contagiosa. See Trichophytosis barbae. 
Sycosis Non Parasitaria. See Sycosis. 
Sycosis Parasitaire. See Trichophytosis barbae. 
Sycosis Parasitaria. See Trichophytosis barbae. 
Sycosis Parasitica. See Trichophytosis barbae. 

Syphilis * (Si 2 f i 2 l-i 2 s). Synonyms : Malum venereum ; 
Lues ; Morbus Gallicus, seu Italicus, seu Hispanicus, seu 
Neapolitanus, seu Indicus ; (Fr.) Verole, or Grosse verole ; 
(Ger.) Lustseuche ; (Eng.) Bad disorder, Pox. 

Whole books have been written upon this disease. Here 
we can only give a brief outline of the disease, and that as it 
affects the skin alone. For a further account of the disease 
the reader should consult the larger special treatises. 

Symptoms. Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 
which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably ninety per cent, 
of the cases this initial lesion is located on the genitals, and 

1 In the description of the syphilides I have followed very closely 
those given by Prof. G. H. Fox, in his Photographic Illustrations of 
Skin Diseases, Treat, N. Y. ; and by Prof. E. W. Taylor in Bumstead 
and Taylor's Pathology and Treatment of Venereal Diseases, Lea, 
Philadelphia, 5th ed. 1883. To both of these gentlemen I would ex- 
tend my grateful thanks for the permission to use their books that was 
so graciously granted to me. 



448 DISEASES OF THE SKIN. 

in the vast majority of these its site in males is the glans and 
prepuce. But the initial lesion may be found on any part 
of the body, and within the mucous cavities. According 
to a table of one hundred and ninety-eight extra-genital 
lesions compiled by Pospelow, 1 the female breasts were 
affected in sixty-nine cases ; the lips in forty-nine cases ; the 
throat in forty-six cases ; and then in very much less fre- 
quency the gums, tongue, chin, eyelids, nose, trunk, anus, 
arms, and legs. Some obscure cases of syphilis are due to 
the initial lesion being in the urethra or upon the cervix 
uteri and thus having escaped detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison; usually the interval is 
less than four weeks ; exceptionally it may be ten weeks. 
This is the period of incubation. Opinions are divided as 
to whether the initial lesion is a purely localized lesion, or 
the expression of a general constitutional infection that first 
declares itself at the point of inoculation. It appears to me 
that the weight of the argument is altogether on the side of 
the last opinion. The initial lesion may assume the form of 
a scaly patch, a dry or moist papule, a superficial erosion, or 
a circumscribed ulcer with perpendicular edge. Induration 
of the base is a characteristic of all forms of initial lesion ; 
it is sharply defined and imparts to the fingers a distinct 
resistance that may be as firm as cartilage. Commonly it 
is parchment-like. To detect it, the lesion must be gently 
pinched between the thumb and finger. It is present coin- 
cidently with the appearance of the initial lesion or within a 
few days afterward. It remains for a long time after the 
disappearance of the lesion — for two or three months or 
longer. The secretion from the initial lesion, when present, 
is thin and chiefly serous. The duration of the lesion is 
variable ; it may disappear before the outbreak of cutaneous 
symptoms, but very often remains for some time after this 
event. Unless there has been ulceration, no cicatrix will be 
left. It may leave a staining of the skin or an induration. 
It is usually a solitary lesion, though it may be multiple. 

1 Arch. f. Dermat. u. Syph., 1889, Hefte 1 u. 2. 



SYPHILIS. 449 

Enlargement of the nearest lymphatic glands accompanies 
the initial lesion. If on the external genitals, it will be those 
of one or both groins. They become hard, and are painless 
and freely movable. Suppuration is rare, and probably the 
result of mixed infection. A pleiad of glands, three arranged 
in a triangle, is quite characteristic of syphilitic infection. 

The initial lesion may at first assume the character of the 
soft sore. This is the result of mixed infection with both 
the virus of syphilis and the local venereal ulcer. The ulcer 
will after a while become indurated and assume its proper 
characteristics. It is in these cases that a suppurating 
adenitis may develop. Modifications from location of the 
initial lesion must also be noted. 1. Of the urethra. These 
may be at the meatus, in the fossa navicularis, or deeper 
parts. Those at the meatus attract attention by causing a 
slight impediment to urination. The lips are found glued 
together by a scanty, viscid secretion. The normal opening 
of the urethra becomes lessened by the induration which 
usually involves the entire circumference of the meatus. 
Those deeper down may give rise not only to interference with 
urination, but also to some pain, and later to a muco-purulent 
or purulent discharge like that of gonorrhoea, because they 
cause a urethritis. They may be felt as a hard, tender, 
circumscribed nodule, and be seen, with the endoscope, as a 
grayish-red erosion of the urethral wall. They may give 
rise to symptoms of stricture. 2. Of the anus. These 
may be without the anus, at its margin, or within the anal 
ring, and usually present a thickened, fissured, ulcerated 
surface. They are of a pale rose tint, and decidedly indu- 
rated. 3. Of the fingers. 1 They may be seated at any part 
of the phalanges, but most often are at the sides or base of 
the nail, or at its free margin. They begin as a papule, 
pustule, excoriation or fissure, and attract attention as an 
obstinate hang-nail or fissure, and we find an irregular, deep- 
red, somewhat elevated mass that is ulcerated and covered 
with a scanty, serous secretion. The finger is apt to be 

1 An admirable study of these lesions by Dr. R. W. Taylor will be 
found in the Medical Record, 1891, xxxix. 69. 



450 DISEASES OF THE SKIN. 

swollen at its end. The epitrochlear and axillary ganglia 
are enlarged, and there may be moderate lymphangitis. 4. 
Of the lip. They are usually covered with a greenish 
brown crust which, when removed, leaves either an erosion of 
little, if any, hardness, or an ulceration of cartilaginous con- 
sistence. The lips may be greatly swollen. They may 
begin as a fissure, or painful excoriation. The lips are 
nearly equally affected, but usually only one. The sub- 
maxillary glands on the side of the lesion are usually first 
affected. 5. Of the tongue. Here we meet with hard cir- 
cumscribed, flat, slightly elevated, dull red, smooth, pea-size 
nodules ; or a round, sharply defined, fleshy red, raised, 
hard ulcer. The cervical and submaxillary glands are en- 
larged. 6. Of the throat. The patient first notices diffi- 
culty or pain in swallowing, the latter in the region of the 
tonsils. Then the submaxillary and cervical glands become 
swollen. Examination shows an intense, limited or diffused, 
general or unilateral, brown or dark redness of the pharynx. 
The tonsils are enlarged, hard, and red, and may be eroded 
and perhaps covered with an ash-colored deposit, a false 
membrane. Or we may find an irregular, hard ulcer with 
gnawed- out edges, and, may be, crater-shaped floor covered 
with dirty-brown or grayish deposit. One or both tonsils 
may be affected. 7. Of the nipple. These are usually mul- 
tiple, and may take the form of an erosion, a scaly patch, or 
an indurated fissure. The size varies from that of a lentil 
up even to three inches in diameter. They are sometimes 
linear, sometimes sickle-shaped along one side of the nipple, 
and sometimes completely encircling the nipple. The nipple 
isred, or dark red, enlarged, hardened, and at times flattened. 
Mastitis may complicate matters. The axillary glands are 
enlarged, as are often those along the upper edge of the 
pectoralis major. On healing, the initial lesion leaves a 
flattening of the nipple, and perhaps a leaning of it to one 
side, characteristics that should put us on our guard in the 
examination of wet-nurses. 

About six weeks after the appearance of the initial lesion 
(it may be as early as the twenty-fifth day, or as late as the 
one hundred and sixtieth), we have the stage of eruption of 



SYPHILIS. 451 

the so-called secondary syphilides. Usually, just before the 
outbreak of the eruption, examination will show a general 
enlargement of the lymphatic glands, especially the epi- 
trochlear and post-cervical. At the time of the eruption, 
or shortly before, the patient will experience certain con- 
stitutional disturbances such as severe headache, malaise, 
pains in the joints, and a rise of temperature of moderate 
extent. In very many cases these disturbances either do 
not exist, or are of so slight severity as not to attract the 
patient's notice. In some cases a more or less profound 
anaemia will manifest itself, or the patient will fall into a 
markedly cachectic condition. Either of these may last far 
into the secondary period of the disease. Weakly individuals 
are more prone to these severe constitutional derangements 
than are the robust, and Fournier teaches that they are most 
apt to appear in women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides ; or the early and late lesions. No 
hard and fast lines can be drawn, as sometimes those lesions 
usually seen late in the disease manifest themselves early in 
its course. The secondary syphilides are those that develop 
during the first two years after infection. They are marked 
by a more or less general and symmetrical dissemination 
over the whole cutaneous surface ; by polymorphism ; by 
running a rather definite course ; by implicating the more 
superficial parts of the skin and mucous membranes ; and 
by leaving little, if any, trace of themselves. In these re- 
spects they differ from the lesions of late syphilis, which are 
grouped and limited to certain regions ; are not polymorphic ; 
show less tendency to run a definite course, involve the 
deeper structures, and are prone to leave permanent scars. 

The eruptions of secondary syphilis are the erythematous, 
the papular, and the pustular syphilide. The first eruption 
of the secondary stage is an erythematous one, the macula?* 
syphilide, or the syphilitic roseola. Unlike other syphilides 
which are all largely composed of new cell growth, this may 
be a hyperemia without cell infiltration. It may be a general 
eruption, though generally most marked upon the trunk 



452 DISEASES OF THE SKIN. 

and flexor aspects of the limbs. The macules are about the 
size of a ten-cent piece, or smaller, of a faint rose-red color, 
circular in form, and little, if at all raised above the skin. 
At times we meet with annular lesions from disappearance 
of the centre of the macule. The lesions, excepting in re- 
lapsing eruptions, are distinct from each other. They be- 
come more evident on exposure to cold, it being no uncom- 
mon thing to see them appear upon the patient's body while 
he is before us stripped for examination. After being out 
for a time their color becomes purplish-red, changing to a 
tawny or yellowish-red, and later to a brownish-yellow. In 
their early stage they can be made to disappear on pressure. 
They either disappear, and leave either no trace or some pig- 
mentation, or they develop into papules. They often coexist 
with papules and pustules. Their evolution usually requires 
a week or ten days ; sometimes it may appear very rapidly. 
It runs a course of one or three months if not removed by 
treatment. Relapses occasionally occur, and these may be 
met with as late as the end of the first year. Then it is usu- 
ally limited to certain regions. It gives rise to no incon- 
venience, and is often overlooked by the patient except when 
it appears on the face or hands. At this time there is apt to 
be an erythematous condition of the pharynx, some sore- 
throat, a rheumatoid affection of the joints, falling of the hair, 
and, perhaps, an iritis, and mucous patches in the mouth, 
upon the vulva, in the groin, upon the scrotum and under 
surface of the penis, and about the anus. 

While the diagnosis is easy, if we have seen the patient 
from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin ; an ex- 
anthem ; a medicinal eruption ; chromophytosis ; and, if we 
have annular macules, trichophytosis corporis. From mot- 
tling of the skin it is diagnosed by the fact that in syphilis 
we have macules of a reddish tint, interspersed with skin of 
normal hue, while in mottling we have light macules with dull 
purplish-red interspaces. From an exanthematous fever it 
is diagnosed by the absence of catarrhal or gastric symptoms, 
and marked pyrexia, and by the sluggish character of its 
lesions. From a medicinal eruption it is diagnosed by an 



SYPHILIS, 453 

absence of high fever and gastric disturbance, and by its 
lesions lacking the urticarial or oedematous character. From 
chromophytosis it differs in having a red rather than a cafe- 
au-lait color, by not being scaly nor capable of removal by 
scraping, by it.s more extensive distribution, and by the ab- 
sence of the microsporon furfur from the scales when they 
are examined under the microscope. From trichophytosis 
it differs in the greater extent of its distribution, and the 
absence of the trichophyton fungus from scales scraped 
from the skin. From pityriasis rosea the differentiation is 
sometimes difficult when the syphilitic macules have assumed 
a ring form. As a rule, there is no difficulty as a pityriasis 
rosea will be scaly, and will present not only rings but 
macules of all sizes, while the syphilitic macules are not 
scaly, and are of more uniform size. 

The papular syphilids, while usually following the ery- 
thematous syphilide, may be the first eruption of the disease. 
Indeed, a great many cases begin as a maculo-papular erup- 
tion. The papules may develop from macules, or may appear 
as papules. Very commonly both macules and papules will 
be present at the same time. If it follows the macular 
form it is apt to appear while the latter is fading. The 
eruption appears as a greater or lesser number of firm, 
rounded, fleshy, red elevations of the skin varying in size 
from a pin's head to one inch in diameter. After continu- 
ing unchanged for a certain time they undergo absorption ; 
the oldest or central part of the papule disappears first, sinks 
in a little, and becomes scaly. It is then that slight pruri- 
tus is complained of. They are scattered over the whole 
cutaneous surface, and often appear in well-marked groups. 
They are prone to relapses, and sometimes are seen as a 
relapsing eruption in the tertiary stage of the disease, when 
they do not occur as a general eruption, but in groups upon 
one or more regions of the body. According to their size 
they have received the names of the lenticular and miliary 
papular syphilide, the former being the larger and most 
common eruption. 

The lenticular papular syphilide has hemispherical or 
flattened lesions forming firm, fleshy, lentil to split-pea sized 



454 DISEASES OF THE SKIN. 

prominences with a smooth and glossy surface. Not infre- 
quently the superficial layer of epidermis over them is want- 
ing from the central portion, and slightly detached around 
the base, forming a fringe called the collarette of Biett. 
This is regarded as a diagnostic symptom. The color of 
the papules is at first light-red ; later it assumes a raw-ham 
color, that is best seen on the legs. From the knee down 
they may have a purplish or hemorrhagic appearance. They 
are usually present in great number and scattered over the 
whole body. On the face they are apt to locate along the 
hair line on the forehead, forming the corona veneris. On 
the scalp they are not very numerous, and are apt to become 
papulo-pustules and crust ; or they itch slightly and are 
scratched. The palms and soles are usually well covered in 
any general outbreak of them. Here they appear as red- 
dish spots under the thick epidermis. Desquamation is often 
seen over the papules in the palms and soles. Sometimes 
the eruption is very slight in extent, only a few scattered 
papules being found. This syphilide develops slowly, runs 
a course of one or two months, and disappears, leaving pig- 
mentation or slightly depressed spots, both of which are not 
permanent. In undergoing resolution they may become 
scaly and form a papulo-squamous syphilide, or pustules 
may form on them during their course, and we then have 
the papulo-pustular syphilide. 

While the form of lenticular syphilide just described is 
the typical one, we see at times larger papules, from three- 
eighths to half an inch in diameter, forming the large flat 
papular syphilide. This rarely, if ever, forms a general 
eruption, but is limited to certain regions. It may occur 
alone or with the lenticular syphilide. It usually follows 
the latter or appears when it is fading. It frequently comes 
as a relapsing syphilide, and often appears late in the second 
year. It has a flattened surface and a circular outline. 
They often coalesce and form patches which frequently 
become scaly and resemble psoriasis. The scaling is 
never very great ; the scales are thin and adherent, and 
do not cover the whole patch. They frequently occur upon 
the flexor aspect of the extremities, and in the bends of the 



SYPHILIS. 



455 



joints. Instead of forming patches by coalescence the indi- 
vidual papule may enlarge at the circumference and become 
depressed at the centre and form circinate lesions, whose 
surface may become moist. 

The moist papule or mucous patch is a modified form 
of the lenticular papule, and is simply a papule subject 
to heat and moisture. They are found where two folds of 
skin rub together, as in the peno-scrotal fold, between the 
scrotum and inside of the thigh, around the anus and vulva, 
and upon mucous membranes. They are of circular shape 
and have a flattened surface which is sometimes depressed 
in the centre. Fresh ones have a bright-red or raw appear- 
ance, but they soon become covered with a dirty whitish 
coating made up of thickened and softened epidermis. About 
the anus and vulva they form large flattened tubercles 
called condylomata lata. (JFig. 42.) They give forth a 

Fig. 42. 




Condylomata lata. (After Taylor.) 



most sickening odor when not kept clean. When in the 
mouth they form " opaline patches," looking as if the mu- 
cous membrane had been pencilled with nitrate of silver. 
They are usually not elevated. If at the angle of the mouth 
they are generally fissured. The mucous patch is one of 
the most contagious of syphilitic lesions, the evidence of 



456 DISEASES OF THE SKIN. 

infection being an initial lesion of syphilis, and not a mucous 
patch. 

The miliary papular syphilide is much rarer than the 
other form of papular syphilide ; in fact, is one of the least 
common of the syphilides. It consists of numerous pin- 
head or slightly larger sized conical papules of a purplish- 
red hue, either disseminated over the whole body or aggre- 
gated in groups forming circles or segments of circles. They 
are developed about the hair follicles and have depressed 
centres. Many of them may be surmounted by small vesi- 
cles or vesico-pustule. This constitutes what has been 
named the vesicular syphilide. Sometimes the lesions when 
closely pressed into patches may be scaly. It may be an 
early lesion or a relapsing later one. In the latter case the 
eruption is not abundant, but in groups. The color is 
brownish-red, and pigmentation and permanent pitting are 
left by them, if they have lasted any time. They rarely 
change into condylomata. Their evolution is rapid, being 
fully developed within two weeks. Pea-sized conical papules 
sometimes are seen amongst the miliary ones. 

The diagnosis of the papular forms of syphilis is generally 
easy because other symptoms of the disease will be sure to 
be present and to establish the diagnosis. It is possible 
that error may arise in distinguishing the patches of scaling 
papules from psoriasis, but here the location of the patches 
upon the flexor surfaces of the extremities, and over the 
bends of the elbows ; the scaling not being commensurate 
with the patch, but having a red, sharply defined border 
about it ; and the well-marked infiltration of the patches are 
all features that would throw out the diagnosis of psoriasis. 
The miliary papular syphilide may be confounded with 
lichen planus or keratosis pilaris, but the absence of itching 
is always in favor of a syphilide, and the conical or rounded 
shape of its papules is in strong contrast with the flat, 
angular, and umbilicated papule of lichen planus. The 
syphilide is also a much more widely disseminated eruption 
than is lichen planus or keratosis pilaris likely to be. 

The pustular syphilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 



SYPHILIS. 457 

always evidence of a poor condition of the health of the pa- 
tient who bears it. It may be the first eruption of syphilis, 
or follow the erythematous or papular form, or occur later. 
It may develop from a macular or papular syphilide, or occur 
with either of them. It may assume varying forms and 
sizes to which in the faulty nomenclature of the older writers, 
have been given the names of non-specific lesions, greatly to 
the confusion of the student. Prof. Geo. H. Fox has done 
well in discarding all such terms, and in describing two forms 
as the lenticular and miliary pustular syphilide. 

The lenticular pustular syphilide (variola-form) occurs as 
a disseminated eruption of small, hemispherical, pea-sized 
pustules, having a hard, papular base and more or less of an 
inflamed areola. It may develop by the softening up of a 
papule, or be a papulo-pustule from the start. In the latter 
case its outbreak will be marked by fever, which is apt to 
recur with each succeeding outbreak. The eruption may be 
general, or upon certain regions. The lesions are discrete, 
and do not form marked groups, although in the pustular 
eruptions, as in others, it is easy for one who looks for it to 
find groupings in circles and segments of circles. A few 
days after they appear they begin to desiccate, and the larger 
ones may umbilicate. At this stage they become crusted 
with a dirty-yellow, brownish, or greenish-brown crust. 
This falls soon and leaves a transient pitting and pigmenta- 
tion. Relapses may occur. 

The miliary pustular syphilide (acne form). This erup- 
tion consists of millet- seed to pinhead-sized acuminate pus- 
tules developing generally from papules and occurring in 
small groups of about the size of a quarter or half dollar. 
It may occur as a general eruption, but is apt to be more 
marked and lasting on the extremities than on the trunk. 
The lesions, especially when occurring upon the flexor aspect 
of the joints, are liable to coalesce. They are developed in 
and around the hair follicles, and may be perforated by 
hairs. They are topped with small crusts. The eruption 
lasts two or three months by the outbreak of new lesions, 
unless controlled by treatment. They leave pigmentation 
and pitting that may remain for several months. 

20 



458 



DISEASES OF THE SKIN. 



While these are the two chief varieties of the early pustu- 
lar syphilide, there is another variety that is called the im- 
petigo-form syphilide, and occurs most commonly in the 
middle or latter part of the first year of syphilis. It may 
occur as late as in the third year. In it the pustules are 
small and flat, and by confluence an impetiginous crust is 
produced. They may form patches with crusting only at the 
border. This form is met with usually on the face, arms, 
and thighs. A few superficial ecthymatous lesions may 
develop, but ecthymatous lesions are usually late manifes- 
tations. 

The diagnosis of the pustular syphilis is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola or varioloid. 
It differs from these in the infiltrated bases of the pustules, 
in being composed of lesions of varying size and age, in not 
occurring in the mouth, and in not running a definite rapid 
course. The miliary form might be mistaken for acne, but 
it is never confined to the face, chest, and back as is acne, 
nor does it present comedones, and so great multiformity of 
lesions. 

Tertiary Syphilides. The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis, and during the first year. As we 
have seen, they may also constitute relapsing eruptions later 
in the disease. Modifications of them may occur late m the 
secondary period or even in the tertiary period. Besides 
these, we have a second group of syphilides that occur any 
time after the first year, and sometimes as late as twenty or 
more years after the initial lesion, when the patient may 
have lost all remembrance of it. To these eruptions the 
name of tertiary or late syphilides is given. Their peculiari- 
ties have been indicated in a general way when writing of 
the early syphilides. They are the tubercular, the squa- 
mous, the pustulo-crustaceous, the gummatous, and the 
ulcerative syphilides. 

The tubercular syphilide occurs in the latter part of the 
second year of syphilis, or later. Exceptionally it may occur 
during the first year as a so-called precocious syphilide. As 



SYPHILIS. 



459 



a rule, the early syphilides cease appearing after six or seven 
months, and then after a varying interval of rest the late 
lesions appear. These may .never come at all, usually as 
the result of judicious treatment, or it may be because of the 
vigorous resistance of the constitution of the individual. 

Fig. 43. 




Annular tubercular syphilide. (After Taylor.) 



Tubercular lesions occur in the form of clustered nodules in 
the deeper parts of the corium. At first they are of faint 
red color ; gradually they become a dull red, and later, still 
darker. In size they vary from that of a split-pea to that of 
a hazel-nut, and constitute firm, elastic, fleshy protuberances. 
They are round, smooth, and somewhat glossy, or flat, rugous, 



460 DISEASES OF THE SKIN. 

and withered. They are frequently scaly. Most often they 
are arranged in circles or segments of circles ; or they may 
be in the form of rings from the first, or in consequence of 
the disappearance of the central members of the group. 
(Fig. 43.) There may be but a single group ; or numerous 
groups may be scattered over the body in a symmetrical 
manner. A very frequent location for them is the posterior 
portion of the neck, or the face. The later in the course of the 
disease they occur, the more apt they are to form but a single 
group. If uninfluenced by treatment, tubercles may continue 
to form for years, the old ones disappearing and new ones 
coming. They disappear either by absorption, or by soften- 
ing and breaking down and forming a sharply cut ulcer with 
perpendicular edges and yellow sloughing base. A number 
of the lesions breaking down at once and coalescing, a large 
ulcer with scalloped border, indicating its composition from 
single lesions, and with more or less thick greenish crust, 
will form. In either case they leave depressed, smooth 
cicatrices, at first pigmented, but later white. They give 
rise to no subjective disturbances. Rarely do they form a 
general eruption. 

The diagnosis of this form of syphilide is usually readily 
arrived at by other symptoms of syphilis. Occasionally it 
may be confounded with lupus vulgaris and leprosy. From 
lupus it is differentiated by the comparative rapidity of its 
course, lupus being a disease of exceeding slowness of de- 
velopment ; by its occurrence in mature years, lupus being 
a disease of youth ; by its sharp-cut round ulcers ; by its 
thick greenish crusts, and by the smoothness of its cicatrices, 
those of lupus being puckered and deforming. Syphilis at 
times bears a striking resembrance to leprosy when its tuber- 
cles are located in the eyebrows, face, and ears, but the 
absence of anaesthesia is a positive diagnostic sign against 
leprosy. Moreover, other symptoms of leprosy, such as 
swelling of the ulnar nerves and peculiar brown patches, 
will be absent. 

The squamous syphilide is not usually described, as it is 
a modified form of either the papular or tubercular lesion. 
In using the term here, I follow my. esteemed master, Prof. 



SYPHILIS. 461 

George H. Fox, and like him adopt it purely on clinical 
grounds. He applies the term to scaly patches of circular 
or irregular form that occur after the first year of syphilis. 
These patches are covered with thin horny scales seated 
upon an infiltrated base. We may have one of two forms : 
the discoid, or the circinate. The discoid form is almost 
peculiar to the palms and soles and neighboring parts, and 
constitutes the only apparent lesion. The round patch of 
varying size, but with a sharply defined reddish seam be- 
yond the scaling, and an infiltrated base, tends to become 
serpiginous, creeping over a considerable portion of the skin. 
Sometimes while it advances at one border, it heals at the 
other ; at other times it clears up in the centre, leaving an 
elevated, scaling marginal ring. The ring may be broken 
and leave a curved line, and if two or more of these lines 
meet we have a gyrate figure. Usually but one palm or 
sole is involved. The skin is apt to crack in the natural 
creases, and then the patient will suffer some pain and dis- 
comfort. It is always an obstinate lesion to cure, persisting 
sometimes for months or years. The circinate form differs 
from the just- described one in being annular from the first, 
and in occurring not only on the palms and soles but else- 
where on the body. 

The diagnosis of this form of syphilide from a squamous 
eczema of the palm is often one of great difficulty. The 
fact that only one palm is affected is always suggestive of 
syphilis. Moreover, in syphilis there is more infiltration 
and much less itching. Indeed, the latter may be entirely 
absent. In syphilis the lesion is often crescentic, with sound 
skin between the horns of the crescent. This is never seen in 
eczema. Psoriasis of the palm is, in most cases, not to be 
thought of as a stumbling-block in diagnosis, as it is exceed- 
ingly rare for psoriasis to affect the palms, and then only as 
a part of a general outbreak of the disease. Some writers 
use the term syphilitic psoriasis for the scaly palmar syphi- 
lide, but it is a most faulty method of nomenclature. 

The pustulo-crustaceous syphilide is characterized by 
large and usually deep-seated pustules or ulcers, covered 
by prominent and peculiar crusts. It is the ecthyma form 



462 DISEASES OF THE SKIN. 

of Taylor and other authorities. It occurs as a late form of 
the disease and as a localized one ; never as a general erup- 
tion. It may occur as a precocious syphilide. It is seen in 
debilitated subjects, and is of gradual development, without 
febrile symptoms, as in the pustular syphilide. It has pref- 
erence for the scalp, face, and extremities. It assumes three 
forms, the ecthymatous, rupial, and pemphigoid. 

The ecthymatous form begins as an eruption of one or 
more round, flat pustules of a diamater of one-quarter to 
one-half inch. They may become as large as a silver half- 
dollar. They have a well-marked inflammatory areola and 
a swollen and indurated base. The pus soon dries and forms 
a flat, greenish or brownish black crust, whose centre is 
sometimes depressed. At first the crust fully covers the 
pustule, but later, either through drying or on account of an 
increase in the size of the pustule, a raw rim is left around it. 
When it is now removed it exposes a typical punched-out 
ulcer with its base covered with sanious pus, which rapidly 
dries into a new crust. Under proper treatment the pustule 
heals, and when the crust falls there will be left a healed or 
nearly healed ulcer. A permanent cicatrix is left when 
healing is completed, which is smooth and white eventually. 
This syphilide is seen most often on the legs and arms. If 
the course of the disease is not checked, the crust is cast off 
by increased suppuration, and the ulcerative syphilide is 
before us. 

The second variety of the pustulo-crustaceous syphilide is 
that which is commonly known as rupia. It differs from the 
preceding variety in being more superficial at the beginning 
and in forming a conical, laminated crust, somewhat resem- 
bling an oyster- shell. It begins either as a superficial pus- 
tule or a small flattened bulla with no inflammatory indu- 
ration. Upon the primary lesion a greenish crust develops, 
under which ulceration, with suppuration, occurs. The mar- 
gin of the ulceration extends a little beyond the original 
crust. A new crust forms upon it, raising up the original 
one, and this process being repeated, at last a laminated crust 
is formed. When the ulceration extends more rapidly in 
one direction than another it will follow that the crust will 



SYPHILIS. 463 

be higher at one end than at the other. Crusts may form 
a half-inch or more in height, and one or two inches in 
diameter. If the lesions are numerous they are usually 
small ; if few, large. When these thick conical crusts are 
removed the ulcer is exposed and is less deep than in the 
ecthymatous form. On healing, a permanent, smooth, white 
cicatrix is left at last. 

The third variety of the pustulo-crustaceous syphilide is 
the pemphigoid or bullous form. It is a very rare lesion in 
acquired syphilis, though quite common in hereditary dis- 
ease. It consists in an eruption of superficial, purulent, flat- 
tened bullae from one to five centimetres in diameter, which 
tend to dry into thick crusts. They are surrounded by a 
dull-red areola, and are soon covered by dark greenish-black 
adherent crusts. If the patient be in fair health the ulcera- 
tion under the crusts will not be deep. If the patient be a 
broken-down subject the ulceration may be very deep. It 
will leave either a pigmented atrophic spot, or a pronounced 
scar, according to the depth of the ulceration. 

The diagnosis of the pustulo-crustaceous syphilide is usu- 
ally easy if the disease is known to the observer, as no 
non-specific disease resembles it closely. The so-called 
ecthyma eachectieum is more inflammatory than is the 
ecthymatous syphilide, and more superficial. The bullous 
syphilide often bears a striking resemblance to pemphigus, 
and can be diagnosed only by a study of all the features of 
the case. 

The gummous syphilide is perhaps one of the most 
characteristic of the late lesions of syphilis. It consists in 
a deposit of gummy material in the skin. The distinction 
between some tubercular lesions and a gumma is often very 
indistinct, and made principally by the size. The gumma 
begins in the subcutaneous tissue and involves the skin sec- 
ondarily. It may take the form of a single tumor, a group 
of nodules, or a diffused infiltrated patch. It is nearly 
always a late lesion, and while it may undergo absorption it 
possesses a strong tendency to break down and ulcerate. 
(Fig. 44.) 

The single tumor begins as a small pea-sized nodule, 



464 DISEASES OF THE SKIN. 

seated in the subcutaneous tissues so deeply as to be appre- 
ciated only by the touch. It grows slowly ; in the course 
of weeks or months it may attain the size of a nut and push 
up the skin over it into an evident tumor, which is movable, 
firm, elastic, painless, and rolls under the finger. Increas- 
ing in size, it involves the skin, which then becomes of a 

Fig. 44. 




Gummata. (After Jullien.) 

dull reddish color. When the skin becomes involved the 
tumor is no longer movable, and soon fluctuation may be 
felt that would lead the inexperienced to open it as an 
abscess. If he did so it would be a mistake. He would 
find only a little pus, a gummy substance, and some 
blood. Left to itself, the tumor may be absorbed, or it may 
break down and ulcerate, leaving a characteristic deep and 
round ulcer. The scalp and forehead are the chosen sites 
for this syphilide, though it may occur elsewhere. It some- 
times attains a large size — as large as a hen's egg. When 
this lesion occurs as a precocious syphilide, it is usually of 
small size and multiple. 



SYPHILIS. 465 

When gummata occur in the form of grouped nodules the 
skin between them is apt to become infiltrated with a gum- 
matous deposit, and the patch will present the dull brownish- 
red color of the late syphilides. The individual members of 
the group run a course similar to that of the isolated gumma, 
but do not attain its size. When they break down they 
form a large irregular ulcer. This variety of the gumma is 
frequently met with upon the scalp, the nose, the outer 
aspects of the extremities about the joints, and around the 
lower portion of the leg and ankle. Diffuse gummatous 
infiltration of the skin probably precedes all serpiginous 
ulcerations. Apart from this it is rarely seen, and almost 
always ends in ulceration. 

Other gummatous deposits are known as syphilitic dac- 
tylitis, admirably described by R. W. Taylor, and syph- 
ilitic bursitis, carefully studied by E. L. Keyes. One being 
a bony and the other a synovial disease, they do not here 
concern us. 

The diagnosis of the gumma must be made with care. 
It may simulate other forms of tumors. It is not as hard 
as the sarcoma, nor as compressible as the lipoma, and it 
invades the skin. An abscess is usually attended by pain 
and signs of inflammation, and runs a more acute course 
than does the gumma. 

The ulcerative syphilide, according to Prof. George H. Fox, 
merits being described by itself, though in itself only a 
sequence of a tubercular pustulo-crustaceous, or gummatous 
syphilide ; because in the majority of cases of syphilitic ulcers 
met with it is hard or impossible for us to say what the pre- 
ceding lesion has been. For convenience, he describes the 
superficial, the serpiginous, and the deep or perforating 
forms of syphilitic ulceration. 

The superficial syphilitic ulcer is circular, with sharply 
cut edges and dirty-yellowish purulent base. It most often 
follows a pustular or pustulo-crustaceous lesion, and may 
appear comparatively early in the disease, especially in de- 
bilitated subjects. They are usually of the size of a quarter 
or half-dollar, and frequently coalesce to form ulcerative 

20* 



466 DISEASES OF THE SKIN. 

patches with scalloped margins. The face and legs are their 
most common sites. 

The serpiginous ulcer is so called because it tends to creep 
over the surface, healing by a cicatrix as it passes along. 
It may develop from a single circular ulcer healing in the 
middle and at one side, and leaving a crescentic or " horse- 
shoe " ulcer at the other side, with a sharp convex margin, 
beyond which is a narrow zone of infiltration upon which 
the ulceration constantly encroaches, while healing at its 
concave border. Or a group of crusted pustules or softening 
tubercles form a number of small round ulcers, of which the 
outer ones usually form a curving line. While those in the 
centre and at one side tend to heal, new lesions develop at 
the periphery of the opposite side, which ulcerate and per- 
haps coalesce, and so the disease creeps on. This form is 
often observed upon the back and on the extremities ; it is 
not particularly painful, and the patient's health may not be 
impaired. 

The deep ulcerations of syphilis result, for the most part, 
from the breaking down of gummatous deposits. The small 
ones are crater-like in shape. Often the opening of the 
softened tumor is smaller than the softened mass, and it is 
not infrequent to find the cavities of adjacent tumors run- 
ning together subcutaneously. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific ulcers 
is most important from a therapeutical standpoint. A 
chronic ulcer located anywhere above the middle half of the 
leg is in most cases syphilitic. If it is not, it is probably 
either traumatic, tubercular, or cancerous. The traumatic 
ulcer is acute and highly inflammatory ; of irregular shape ; 
has a history of traumatism ; and heals rapidly, excepting 
in very broken-down subjects, under simple dressings. The 
tubercular ulcer, if from broken-down caseous glands, has 
a history of the previous glandular affection ; is irregular in 
shape ; often presents a number of sinuses and ridges of in- 
flamed tissues ; and runs a sluggish course. If it is a lupous 
ulcer there will be found somewhere in its neighborhood the 



SYPHILIS. 467 

characteristic apple-jelly-like tubercles ; there will be a his- 
tory of lasting from early life ; the edges of the ulcer will 
be shelving or undermined; and there will usually be more 
or less deforming cicatrices present. A cancerous ulcer, 
usually an epithelioma, will have a history of beginning in 
a pimple, wart, mole, or such like ; will be irregular in 
shape with an uneven floor ; will be apt to be attended by 
lancinating pain ; will usually be a single lesion, located on 
the face ; and will have a raised, waxy, rolled-out border 
over which delicate bloodvessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irregular in 
shape with shelving edges, rather superficial, surrounded by 
a brawny, infiltrated, brownish or dark-red tissue with more 
or less scaling, and there are varicose veins above it, we 
have to do with the so-called varicose ulcer. This is in 
sharp contrast with the round, or scalloped bordered, deep, 
punched-out ulcer with perpendicular edges and greenish 
base, around which there is but a small zone of redness. 
The diagnosis of syphilis is strengthened when we find a 
number of ulcers, or the cicatrices of old ulcers. As a rule 
the syphilitic ulcer is located on the posterior surface of the 
upper half of the leg, while the varicose ulcer is on the ante- 
rior surface of the lower third of the leg. The diagnosis 
from a traumatic ulcer has already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation follow- 
ing a syphilide which is sufficiently common, and due to a 
staining of the skin with hgematin. It is a true pigmenta- 
tion without antecedent lesion, and is most always seen on 
the sides of the neck, and in women. It is composed of 
irregularly round or oval spots, one-eighth of an inch to 
one inch in diameter, with ill-defined margins, and cafe-au- 
lait color, which does not fade on pressure. The color may 
be very faint. They may be discrete or confluent. When 
they are very numerous they have been compared by Four- 
nier to a " network of lace with large meshes." It is one 
of the rarer manifestations of syphilis. 



468 DISEASES OF THE SKIN. 

General Diagnosis of Syphilis. Having now studied 
briefly the various cutaneous lesions of syphilis, we are pre- 
pared to state those general features of the sylphilides that 
serve to distinguish them from other diseases of the skin. 

One marked feature of them is that they do not itch. 
Itching does occasionally occur with the scaling papular 
syphilide ; and in some cases the patient will complain of 
an itching of the skin that is quite independent of syphilis, 
but in themselves they do not itch. 

The early eruptions of syphilis exhibit a marked poly- 
morphism, many different lesions being often present at the 
same time ; as, for instance, macules, papules, and pus- 
tules. The late eruptions exhibit a strong tendency to 
grouping of the lesions in circles and segments of circles. 

The color of the lesions is peculiar, and perhaps may be 
best described as that of raw ham, though the classic term 
is " copper. ' ? This color is by no means always present. 
It is not seen in the early bloom of the early lesions, but is 
pretty sure to be found in those that have existed for some 
time, and in the late lesions. The color of a lesion on the legs, 
it must be remembered, must not be regarded for purposes 
of diagnosis ; it is upon the arms, face, trunk, and thighs 
that we must look. 

Painlessness is often a suggestive symptom pointing 
toward syphilis when we have to decide as to the nature of 
an ulceration. 

It is well not to lay too much stress upon the history of 
the case in making up our mind as to a late syphilide, be- 
cause with the best of intentions the patient may forget hav- 
ing had an insignificant initial lesion some twenty or per- 
haps thirty, years before. 

Space will not permit of our here detailing the differential 
diagnosis between syphilis and the many diseases which it 
may simulate from time to time. For this the reader 
must be referred to the sections upon eczema, psoriasis, 
lupus, alopecia, etc. 

Etiology. That acquired syphilis is due to contagion 
we know. Further than this we know little of certainty. 
Various attempts have been made to prove its bacillary 



SYPHILIS. 469 

origin, by Lustgarten and others, but at present the best 
authorities are by no means agreed upon the correctness of 
this theory. 1 We can, in the meantime, speak of its being 
due to a specific virus. The microbian theory is also ap- 
plied to all pustular syphilides, and we are taught that they 
are the result of an infection of the specific lesion by the 
pus coccus. 

Hereditary Syphilis. Before entering upon the study 
of the treatment of syphilis, we must stop a while to 
consider hereditary syphilis. This differs from the acquired 
form in having no initial lesion, the disease being acquired 
in utero from either one or both parents. We cannot enter 
upon a discussion of the many conflicting theories as to 
whether or not the child is diseased on account of springing 
from a diseased ovum, or spermatozoa ; or the possibility of 
the disease, acquired by the mother after her pregnancy, 
reaching the foetus through the placental circulation ; or 
like interesting questions over which the battle rages. For 
us now it suffices to make the bald statement that the dis- 
ease may be acquired from one or both parents. It is most 
sure to be acquired from the mother, and it may be in- 
herited by the foetus from a mother infected some months 
after conception. It is possible for a woman to show no 
sign herself of syphilis, and yet to give birth to a 
syphilitic child. It is exceedingly rare for the apparently 
healthy mother of a child hereditarily syphilitic to be in- 
fected by it. As a result of syphilitic infection in utero, the 
child may be born prematurely, and dead ; it may be 
born at term, dead, and showing specific lesions ; or 
it may be born alive with some syphilitic eruption ; or, as is 
commonly the case, the eruption may not appear before the 
second or third week. Miller, 2 from a study of one thou- 
sand cases of congenital syphilis in a foundling hospital in 
Moscow, found that the first appearance of the disease 
was in the first month of life in 64 per cent, of the cases ; 

1 For a good study of the probable origin of syphilis consult Finger, 
Archiv. Derm. und'Syph., 1890, p. 331. 

2 Jahrb. der Kinderheilk., 1888, xxvii., Heft 4. 



470 DISEASES OF THE SKIN. 

and in the second month in 22 per cent. In congenital 
syphilis there is a marked absence of that sequence of events 
more or less observed in acquired syphilis, but the diagnosis 
is usually quite as easy. The earliest eruption to appear, 
as to point of time, is, according to Miller, the bullous 
syphilide, which he met with in 25 per cent, of the cases. 
One of the earliest and most characteristic symptoms of 
hereditary syphilis is " snuffles," due to an ozaena, which 
gives the child great discomfort by interfering with breathing 
and nursing. 

The erythematous syphilide is, according to Taylor, the 
most frequent and earliest eruption ; according to Miller, 
it occurs in but 45 per cent, of the cases. It begins on 
the lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide in 
children is seen upon the inside of the thighs, about the 
anus, and on the buttocks, and may extend down to the 
feet. It is patchy in character, the patches being either of 
small size, or large by the coalescence of several smaller 
ones. It differs from intertrigo by its patchy character, by 
its darker color, and by its wider distribution. 

The papular syphilide and its modified forms of the mu- 
cous patch and the condylomata lata, are the most common 
of the congenital lesions. The lenticular syphilide, large 
and small, is met with far more frequently than the miliary 
papular syphilide. It is usually a symmetrical and gen- 
eral eruption. They may be smooth or scaly, and always 
have the raw-ham color. Mucous patches are very often at 
the junction of the mucous membrane and the skin, as on 
the lips or anal orifice. The movements of the parts will 
give rise to painful fissures, rhagades, which constitute a sign 
of hereditary syphilis as characteristic as the " snuffles." 
These rhagades Miller met with in 70 per cent, of his 
cases. Mucous patches also occur in the cavity of the 
mouth. Condylomata lata occur where two skin surfaces rub 
together, and specially when there is more or less moisture, 









SYPHILIS. 471 

as about the anus and genitals, in the groins and axillae, 
and between the fingers and toes. Their color is usually gray- 
ish-pink to dark-brown ; their size varies greatly, and their 
surface flat, or fissured and ulcerated, and exuding an offen- 
sive secretion. They are characteristically located when at 
the angles of the mouth, in combination with mucous patches 
in the mouth with rhagades between. 

The pustular syphilide may be general, but is usually 
most pronounced on the thighs, buttocks, and face. They 
show a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but 
usually not till late in the disease. 

The vesicular syphilide is a rare form of early congenital 
syphilis of severe type. It is never general, but appears as 
groups of closely packed together vesicles upon the chin, 
about the mouth, or on the nates, forearms, hypogastrium, or 
thighs. They are seated upon infiltrated, brownish-red 
bases. The larger vesicles may be seated upon papules. 
This eruption is apt to be associated with a pustular or bul- 
lous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. Miller 
found it in twenty-five per cent, of his cases. It frequently 
exists at birth or as the earliest syphilide, and is indicative of 
a severe form. It is most commonly seen on the palms and 
soles, which are often covered with the lesions, while few, if 
any, are on the trunk. The face is a favorite location for 
the eruption. They are either tense or flaccid ; at first have 
sero-purulent contents that soon becomes purulent. They 
are seated upon a raw-ham-colored infiltrated base. Hem- 
orrhage into them not infrequently occurs. When they 
rupture or dry up they exhibit an unhealthy-looking ulcer- 
ation that soon becomes covered with a greenish crust. Some 
of them may dry up with little, if any, ulceration. It rarely 
relapses. It differs from pemphigus in occurring upon the 
palms and soles, while sparing the trunk, and in the profound 
cachexia and the presence of other signs of syphilis. 

The tubercular syphilide is not common, and is always a 



472 



DISEASES OF THE SKIN. 



late lesion. While it may be seen as early as the sixth 
month, it is more apt to occur much later as a relapsing 
syphilide. In appearance and course it resembles the same 
lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation of 
disease, and is sometimes met with in early adult life as a 
lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish-red, dry, 
shiny, and fissured. 

Besides the skin lesions the infant bears certain unmistak- 
able signs of syphilis. It has a marked pallor, and, no mat- 
ter how blooming it may appear at first, it soon loses flesh 

Fig. 45. 




Hutchinson's teeth. 



and assumes " an old man " countenance It has a character- 
istic, hoarse, toneless cry, which once heard will be remem- 
bered. Its hair is scanty, its nose is apt to be flattened, and 
altogether it is a most woebegone-looking object. The skin 
eruptions usually occur within the first six months of life, 
and if the child can be brought through that period it may 
suffer no more. Nevertheless, congenital syphilis, like the 
acquired disease, may be latent for years to crop out once 



SYPHILIS. 473 

more. The victims of congenital syphilis sometimes show 
the notched or peg-shaped teeth regarded by Hutchinson as 
a certain sign of the disease. (Fig. 45.) This appearance 
is presented by the second set of teeth only, and is not abso- 
lutely diagnostic, as the same has been met with in scrofula. 
The two middle upper incisors are those which are depended 
on for diagnosis. " They are small, often converging, some- 
times diverging. The cutting edge of the teeth is some- 
times narrowed, rounded off. They are stunted and badly 
developed, often marked with seams in front, and of a dirty- 
brownish color, but their chief peculiarity is found in their 
edges, which, being thin when cut, break off centrally, leav- 
ing a broad, shallow, vertical notch on the lower border of 
the tooth." (Keyes.) It is subject to diseases of the bones, 
one of the most characteristic of which is dactylitis. Space 

Fig. 46. 




Dactylitis. (After Bergh.) 

will not permit of a detailed description of the bone and 
other lesions apart from those of the skin. 

Treatment. The treatment of syphilis is by the use of 
both constitutional and local remedies, and by a constant 
and long-continued watchfulness on the part of the physician 
over the patient's hygiene and general well-being. One 
chief obstacle to the successful treatment of a case is the 
patient's lack of faith in his physician. Most patients, just 
as soon as the eruption for which they sought advice fades 
away will cease coming to the physician, and will pay little 
heed to his warning that unless they keep themselves under 
medical supervision for three or four years they will be 



474 DISEASES OF THE SKIN. 

liable to serious troubles later on. Nevertheless, our first 
duty is to so instruct them. Then before putting the patient 
upon a regular course of treatment, we should give him care- 
ful direction as to his exercise, liberal diet, and bathing, and 
should stop his alcohol, insist upon his taking plenty of 
sleep, and giving up the use of tobacco. This last is not 
only to put him in better general condition, but also to pre- 
vent mucous patches in the mouth. The patient should be 
cautioned against drinking out of public drinking-cups, and 
apprised of the danger of infection of others by means of 
table utensils, pipes, and the like. Now he is ready for his 
course of treatment. 

Constitutional Treatment. The drugs employed and 
found of value in syphilis are chiefly but two, namely : mer- 
cury, and iodine in combination with sodium or potassium. 
These drugs are given in varying combination, and during 
varying periods, according to the views of different physi- 
cians. Mercury is the remedy relied on most for combating 
the disease, and should be used under ordinary circum- 
stances by itself alone during the first year or two of the 
disease. The iodides exercise a marked control over the 
ulcerative syphilides, and in the late or precocious manifesta- 
tions of the disease. By some they are given continuously or 
as the sole remedy in late syphilis, but the best practice is in 
favor of their administration either with mercury or instead of 
mercury for a short time. Treatment should be begun as 
soon as we are sure that the patient has syphilis. As an 
element of doubt may often enter into our diagnosis of the 
initial lesion, it is a good general rule not to administer specific 
treatment until the appearance of some secondary symptom. 
This plan has the additional advantage of producing a moral 
effect upon the patient, who, if he sees an eruption upon 
himself, will be more apt to believe that he has syphilis, and 
to submit himself to a thorough course of treatment. 

We will consider first the treatment of early syphilis and 
the use of Mercury. This drug, regarded by the majority of 
physicians as the sheet-anchor in the treatment of syphilis, 
is administered, for its constitutional effect, by the mouth, 
by inunction, by fumigation, and by hypodermatic injection. 



SYPHILIS. 475 

Of these different methods the most frequently employed 
is the first — that is, by the mouth. The salt of mercury that I 
most frequently use is the protiodide, otherwise called the green 
iodide. This may be exhibited either in pill, tablet triturate, 
or granule ; and as the tablet triturate is easily obtainable, 
very reliable, and quite inexpensive, my preference is for 
that preparation. Keyes prefers the granules of French 
manufacture, and says that the very objection raised by 
many authorities to the use of the protiodide, namely, its 
irritant effect on the intestinal tract, is its shining virtue, 
because instead of giving warning of intoxication by causing 
salivation, it does so by causing diarrhoea. The dose to 
begin with should be from one-sixth to one-fifth of a grain 
three times a day after meals, and the number of pills in- 
creased every third or fourth day until there is a little 
" colicky diarrhoea." The dosage should be then continued 
at the same number of pills, until the symptoms are con- 
trolled. Then we can reduce it to half the number. It may 
be necessary to give a little opium at the same time with the 
mercury in order to control the diarrhoea if it is deemed 
advisable to continue at the point of full tolerance, and this 
not only with the protiodide but with other salts. Practi- 
cally the dose of the protiodide may be put at four or five of 
the one-fifth-grain tablets, and three or four of the quarter- 
grain ones. 

Many prefer to use metallic mercury, hydrarg. cum creta, 
or calomel in the dose of one or two grains two or three 
times a day after meals, increased every three or four days 
sufficiently to influence the eruption. Salivation is, in the 
general run of cases, to be avoided. Some authorities, and 
among them Robt. W. Taylor, prefer to combine a tonic 
with the mercury, as follows : 



H • PiL hydrargyri, ^ij ; 2 

Ferri. sulphat. exsic, ^j 5 1 

Ext. opii, gr. v; 
Div. in pil. no. xl. 



66 
33 
30 M. 



Or, 

Div. in pil. no. xl 



R . Hydrarg. cum cretse ^ij ; 266 

Quinise sulphat., §j I lj33 M. 



476 DISEASES OF THE SKIN. 

In severe cases where it is necessary to get the patient 
rapidly under the influence of mercury, calomel in one- 
tenth-grain doses in the form of tablet triturates may be 
given every hour until the gums become tender. Then the 
calomel should be stopped and the treatment continued with 
a small dose of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of -^ to y 1 -^ of a grain in solution. It is 
usually given in compound syrup of sarsaparilla or some 
bitter infusion. The most common mode of administering 
it is in combination with the iodide of potassium, the so-called 
mixed treatment, the formula for which will be given later 
when speaking of the treatment of late syphilis. The best 
opinion is in favor of reserving the use of iodine until the 
early lesions are over. The tannate of mercury is well 
spoken of. Space will not allow of mentioning the other 
salts of mercury that have been recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously. 

Where practicable the use of mercury by inunction 
is the speediest and best way of getting the patient under 
the influence of the drug. Its great advantages are 
the promptness with which it acts, and the sparing of the 
stomach and intestinal tract. Its great disadvantages are 
that it is a dirty method, impracticable with most patients, 
as it attracts notice from his friends and attendants ; and 
the difficult encountered in getting the patient to carry out 
the treatment with thoroughness. It is admirable for hos- 
pital treatment. The patient is to be told to rub into his 
skin, once a day, a piece of ungt. hydrarg. cinereum of the 
size of a hazel-nut. He is to divide the mass into two equal 
parts, and work it in with the heel of his hand for about 
fifteen minutes, while he sits before a fire or in a warm room. 
Before beginning the inunctions he is to take a warm bath, 
or to bathe the parts about to be rubbed, so as to open the 
pores of the skin. The first day he is to rub the ointment 
into the bends of both elbows ; the second day, over the 
sides of the chest ; the third day, over the abdomen ; the 



SYPHILIS. 477 

fourth day, inside of the thighs ; and the fifth day, behind 
the knees. That is, he is to choose the parts least covered 
with hair ; and to change the sites of the inunctions so as to 
avoid setting up a mercurial eczema. On the sixth day he 
is to take another bath, and begin again on the seventh day. 
The treatment is to be pursued until active symptoms of 
the disease are overcome, when all treatment may be sus- 
pended. A thorough course of, say, eighty or a hundred 
inunctions is said to be often followed by a permanent cure. 
If the inunctions are to be made by an attendant he should 
wear a stout rubber glove. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus, and 
a great amount of time and trouble. Inasmuch as it pos- 
sesses no advantage over inunctions, we will say no more 
about it. 

The hypodermatic injection method of administering mer- 
cury, or rather the deep intra-muscular method, was first 
advocated by Scarenzio in 1854, and of late years has been 
much experimented with. The injections are usually made 
deep down in the gluteal region, behind and above the great 
trochanter. They are usually painful ; often followed by 
abscesses ; require daily or frequent visits to the physician's 
office ; and do not seem to be followed by sufficiently lasting 
effects to warrant their frequent employment. They are 
useful where we wish to have a very prompt effect from- the 
mercury, as in a malignant precocious case of syphilis ; or 
where the stomach must be spared ; or where the disease has 
not yielded to the ordinary plans of treatment. Patients in 
this country seem to object very strongly to their employ- 
ment. A vast number of salts of mercury and combinations 
have been introduced, each one of which has been found by 
its introducer the best and most reliable. An admirable 
study of them will be found in Hare's System of Therapeutics, 
vol. ii., by Prof. R. W. Taylor. Here we can indicate, and 
briefly, but a few. Taylor gives one of corrosive sublimate, 
gr. xl ; glycerin, 5j ; distilled water, 5iij ; of which twelve 
drops are used at each injection. The albuminate of mer- 
cury, dose 15 minims; the formamide (Liebreich), dose 



478 DISEASES OF THE SKIN. 

one-half to a whole Pravaz syringeful of a one per cent, solu- 
tion ; calomel, 1 part, to liquid vaseline, 12 parts, dose a 
half Pravaz syringeful once a week ; " gray oil," composed 
of 20 parts of pure mercury, 40 of liquid vaseline, and 5 of 
ethereal tincture of benzoin, dose one-third of a syringe- 
ful every ninth day ; l salicylate, 15 grains to the ounce, and 
many others. A final judgment as to the comparative merits 
of the many salts cannot yet be given. 

Duration of mercurial treatment. How long the patient 
should take mercury is a question, the answer to which is 
very variously given by different authorities. Keyes puts 
it at from eighteen months to four years. Taylor says, " at 
least two years to two years and a half, counting from the 
date of the commencement," but he advocates intermissions 
of from two to three months, iodide of potassium being given 
in the meantime. Schwimmer 2 advocates giving mercury 
for two or three months, and then one of the iodides for two 
months ; after four or five months of treatment, making a 
pause of two or three months, treating any local lesion 
locally, and then repeating the course. Fournier 3 usually 
administers mercury for six to nine weeks ; then pauses six 
weeks ; then gives another six weeks' medication. During 
the first year he puts the patient through four courses ; 
during the second year, three courses ; and during the third 
year, two courses. During the fourth year he gives the 
iodide alone for six weeks, with corresponding intervals. 
Crocker advices stopping mercury about every six weeks to 
give the iodide for a week or ten days. At the end of six 
months, if the patient has been free from symptoms for two 
or three months, a month's pause may be made, to be fol- 
lowed by a six weeks' course of mercury. And so through 
the first year. During the second year he alternates a six 
weeks' mild mercurial course with a one or two weeks' course 
of the iodide. If still free from lesions, treatment may be 
suspended until some symptom crops out. 

1 Leloir and Tavernier : Giorn. ital. d. Mai. Ven. e del Pelle, 1889, 
xxiv. 247. 

2 Second Supplement to the Monatshefte f. prakt. Dermat., 1888. 

3 Gaz. des Hop. 1889, No. 103 



SYPHILIS. 479 

Against these advocates of long-continued mercurial treat- 
ment there are others, no less eminent, who advocate the 
administration of mercury only during the duration of the 
symptoms, and for a few months afterward ; then they advise 
to suspend all treatment until some new outbreak of the 
disease calls for it. In combating so insidious a disease as 
syphilis, it seems to me wisest to err rather on the side of too 
long continued treatment than on that of a too short course. 

Late Syphilis. If a patient comes to us with a late 
syphilide who has not been under systematic treatment, the 
so-called mixed treatment will be most appropriate to his 
case. As usually administered it is made up according to 
one of the following formulas : 

R. Hydrarg. bichlor.,Yel \ . .. 

Hydrarg. biniodidi, j o -J J- 

Potass, iodidi, 3J~ij- 

Inf. gentian co., vel \ l ? ' 

Syr. sarsaparillse co., | ^ " M. 

Dose : A teaspoonful three times a day after meals. 

Or, 

H. Hydrarg biniodidi, gr. ss-ij. 

Ammon. iodidi, sjss. 

Potass, iodidi, 3 ij- 25 j . 

Syr. aurant. cort., Ei ss ' 

Tr. aurant. cort., 3j. 

Aquae, q. s. ad ^llj. M. 
Dose : A teaspoonful, in water, three times a day. (Keyes.) 

If a patient comes to us with a gumma, an ulcerative 
syphilide, a group of serpiginous turbercular syphilides of 
the tertiary period ; or if any of these or other deep lesions 
threatening destruction of tissue appear early in a case of 
prococious or malignant syphilis ; or if the disease attacks 
the nervous system, the larynx, pharynx, or eye ; in fact, at 
any time when there is need of prompt effects, we must ad- 
minister the iodides. The iodide of potassium is most gen- 
erally used, and next to it the iodide of sodium. There 
is no set dose for the iodide. It is best given in a dose of 
five grains in solution, in water, three times a day, before 
meals, diluted in milk or in Vichy or soda-water ; or some 



480 DISEASES OF THE SKIN. 

three hours after meals. Delavan 1 has found that the iodide 
can be given most satisfactorily by putting five drops of a 
saturated solution in the bottom of a small tumbler, with 
fifteen drops of essence of pepsin, and pouring upon it two 
ounces of warm milk. This is to be set away in a cool 
place, and will form a rennet custard, which can be easily 
swallowed. This a good method when we wish to give 
nourishment with the medicine, and the mixture can be 
given a pleasant taste by adding a teaspoonful of sherry 
wine. 

The dose should be increased by one or two drops each 
day ; that is, six drops t. i. d. ; then seven drops t. i. d., 
and so on, until the nose runs and the eyes water, or 
some symptom of iodism develops. The most convenient 
method of administration is to have a solution made con- 
taining one grain of the iodide to each drop of the solution, 
so that every drop represents a grain. Most patients bear 
iodine well, but in some even drop doses produce iodism. 
Iodic acne is very often induced, but should not cause us to 
stop using the drug. It is advisable to suspend the admin- 
istration of the iodides from time to time, and to give mer- 
cury, which, after all, must be depended on for curing 
syphilis. 

Now and again we will meet with cases that do not im- 
prove either under mercury or iodine, but relapse and relapse. 
Such cases should be sent out of town, ordered change of 
air for a time, and put on a purely tonic course of treatment. 
Very often when the patient returns home he can take his 
medication easily, and the previously obstinate lesions will 
yield readily. This is but what we said at first : the pa- 
tient's general condition must all the time be carelully 
watched over. 

Salivation is an unpleasant accident that may occur either 
under the use of mercury or iodine. At one time it was 
quite common ; indeed, mercury was purposely pushed so 
far as " to touch the gums,' ? and of course often was over- 
done. Its symptoms are tenderness of the teeth, so that 

1 Med. Kecord, 1891, xl. 651. 






SYPHILIS. 481 

pain is felt when they are snapped together, one jaw on the 
other ; the gums are swollen ; there is a metallic taste in 
the mouth ; a fetid odor of the breath ; increased flow of 
saliva by day and night ; all the mucous membranes of the 
mouth are swollen, so much so as to interfere with mastica- 
tion and deglutition, and in very bad cases there may be 
ulceration, loosening and fall of the teeth, and caries of the 
bones. 

Prevention is always better than cure, and to this end we 
should see that our patient's teeth are in good order before 
beginning treatment, and direct him to wash his mouth fre- 
quently with chlorate of potash solution, ten or fifteen grains 
to the ounce, and keep his teeth clean. The patient should 
be seen frequen tly at first, so as to stop the mercury before 
salivation attains any serious degree. Salivation having 
begun, the mercury must be stopped, and the potash solution 
in some strength may be continued, and one or two drachms 
of the salt swallowed during the day. Dilute solutions of 
Labaroque's solution, or permanganate of potash, or other 
astringent, may be used for a gargle and mouth-wash. A 
laxative should be administered, the patient kept warm in 
bed, and if necessary an anodyne given. 

Local Treatment. While internal treatment by mer- 
cury and the iodides is quite competent to remove the syph- 
ilodermata, their disappearance can be materially hastened 
by local treatment by means of mercurial applications. 
Ointments of metallic mercury, of the ammoniate, the red 
oxide, and the oleate, with solutions of the bichlorides are the 
preparations most generally employed. 

Many attempts have been made to abort syphilis by ex- 
cision of the initial lesion, or its destruction by means of 
caustics. These have been failures in most instances. This 
is not to be wondered at in the light of R. W. Taylor's 
recent studies, 1 which show that " in the very first days of 
syphilitic infection the poison is deeply rooted beneath the 
initial lesion and extends far beyond it, infecting all the 
parts beyond, even to the root of the penis." The initial 

1 Med. Eec, 1891, xl. 1. 
21 



482 DISEASES OF THE SKIN. 

lesion should be dressed with iodoform or calomel, or kept 
covered with dry lint powdered with either of these. 

It may be said that in all the early and generalized syph- 
ilides local treatment need practically to be applied only to 
lesions on exposed parts ; that is, face, neck, hands, and 
wrists. The erythematous syphilide is usually so epheme- 
ral that no local treatment is necessary. Mercurial baths 
may, however, be used for general outbreaks of syphilis. 
If the erythematous lesions persist upon the exposed parts, 
their departure can be hastened by the use of the ointment 
of the ammoniate of mercury rubbed in morning and night. 
The same ointment may be applied to the papular syphilide. 
A still more prompt effect can be produced, if the patient 
can be seen often enough, by the physician touching each 
lesion with a solution of the bichloride in alcohol, five or 
ten grains to the ounce, according to the size of the lesions 
and the profuseness of the eruption. Of course, if the erup- 
tion is very profuse this plan cannot be followed. It is 
most applicable to a sparse and relapsing eruption. The 
mucous patch should be touched with the nitrate of silver 
stick. Condylomata are best treated with dusting powders, 
preferably calomel freely applied, and covered with absorbent 
cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but. will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber next 
the skin for several days, and then use the ointment. If 
they are covered with a very much thickened epidermis we 
may have to remove this by using salicylic acid as in chronic 
squamous eczema. Mercurial plaster worn continuously is 
efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows unmis- 
takable evidences of containing pus. 



SYPHILIS. 483 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform or 
aristol. If they become sluggish, they may require stimula- 
tion just as a simple ulcer does. To this end we may touch 
them with balsam of Peru, or add the same to our mercurial 
ointment. Some ulcers will do best under the treatment 
applicable to a simple ulcer, while the iodide of potassium is 
pushed. 

Treatment of Congenital Infantile Syphilis. The 
most popular method is to spread upon pieces of flannel a 
piece of mercurial ointment of about the size of the end of 
the finger, and tie this one day over the elbows ; another day 
over the groins ; another, over the knees ; and another, over 
the abdomen, allowing the movements of the child to work 
the ointment into the skin. Or hydrarg. cum creta, one 
grain three times a day may be given by the mouth. Monti 1 
recommends the following : 

R. Calomel pur., 1 

Ferri lactatis, 2 

Sacch. alb.. 3 M. 

Ft. in pulv. no. x. 

Sig. 1-4 powders daily. 

The greatest attention must be given to the hygiene of 
the child, and to its diet. The nose must be kept clear, and 
if this is not practicable it must be fed with a spoon. After 
the disappearance of symptoms, put on tonics, one of the best 
being the syrup of the iodide of iron. In all other respects 
the treatment of infantile syphilis is the same as that of the 
acquired form. Kaposi commends the tannate of mercury for 
children ; dose, J gr. to f gr., t. i. d. 

Prognosis. The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many cases go no further than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In 
debilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 

1 Archiv f. Kinderheilk., 1885, vi. 1. 



484 DISEASES OF THE SKIN. 

course, no one being able to promise confidently, no matter 
with what treatment, that relapses and late visceral syphilis 
will not occur. Therefore, the prognosis should be guarded, 
while it is remembered that rare cases of secondary infection 
attest the possibility of complete recovery. 

The prognosis of congenital syphilis is not as good as is 
that of the disease as it affects adults. Many, perhaps most, 
of the cases seen in public institutions die. In private prac- 
tice more can be done, and we should always count upon the 
remarkable reparative powers of childhood in making our 
prognosis. A great deal will depend upon the inborn vigor 
of the child. 

Syringomyelia (Si 2 r-i 2 n-go mi-el'i 2 -a s ) is a disease of the 
spinal cord, the consideration of which belongs rather to the 
neurologist than the dermatologist. It interests us because 
various cutaneous lesions occur during its course, such as 
glossy skin, hyperkeratosis, hyperidrosis, and paronychia 
with necrosis of the phalanges ; and because in some phases 
it resembles certain stages of leprosy. 

Syringocystadenoma. This is the name given by 
Unna and Torok 1 to a peculiar disease of the skin that 
probably begins in embryonic sweat glands. The case they 
described was of seventeen years' standing and was located 
upon the chest and abdomen. It began in the neighborhood 
of the axillae and spread forward and downward. The erup- 
tion consisted of a number of small, round, hard, raised 
papules of the color of the skin, which tended to grow larger 
and become of a bluish-red color. There were no subjective 
symptoms. It is supposed by Besnier to be identical with 
the multiple tuberous lymphangioma of Kaposi. 

Tache Atrophique. See Atrophoderma. 

Tache Bleue. See Pediculosis. 

Tache Cafe-au-lait. See Nrevus. 

Tache Congenitale. See Nsevus. 

Tache de Feu. See Naevus. 

1 Monatsheft. f. prakt. Derm. 1889, viii, 116. 



TELANGIECTASIS. 485 

Tache Hemorrhagique. See Naevus. 
Tache Pigment aire. See Nsevus. 
Tache Vasculaire. See Nsevus. 
Tache Vineuse. See Naevus. 
Tache Hepatique. See Chromophytosis. 
Tache Ombrees. See Pediculosis. 
Tan. See Lentigo. 
Tanne. See Acne. 

Tattoo. These well-known stainings of the skin by means 
of India-ink, vermilion, charcoal, and gunpowder, although 
at first objects of pride to the boy or girl, later are apt to 
become objects of aversion. They are very difficult to 
remove ; indeed, it is almost impossible to remove them if they 
are at all extensive. Patient perseverance in going over 
and over the small ones, that cannot be excised, with the 
electrolytic needle will sometimes greatly lessen them, 
though, of course, we thereby substitute a white cicatricial 
spot for a colored one. The needle should be introduced 
perpendicularly to the skin and deeply, and numerous punc- 
tures arranged in rows thus made. This, of course, is a 
very slow procedure. Powder-grains may be removed by 
Keyes's punch, by making a half turn over them, and then 
snipping off the small piece with the scissors. (Fig. 47.) 

Fig. 47. 



O "fa OF REAL SIZE. 

Keyes's punch. 

Teigne Faveuse. See Favus. 

Teigne Granulee. See Pediculosis. 

Teigne Pelade. See Alopecia areata. 

Teigne Imbriquee. See Trichophytosis corporis. 

Teigne Tondante seu Tonsurante. See Trichophytosis 
capitis. 

Telangiectasis (Te^-a^-jiWk'taVi's). This is an ac- 



486 DISEASES OF THE SKIN. 

quired dilatation of the bloodvessels. The condition is well 
seen in rosacea. But it seems to me best to reserve the 
term for those cutaneous lesions in which acquired dilata- 
tion of the bloodvessels of the skin is the only condition 
present. 

Symptoms. The most common form of the disease is 
what is vulgarly called " spider cancer " or ncevus araneus. 
It occurs in nearly all cases upon the cheeks, near the eye- 
lids or bridge of the nose, or indifferently, but may occur 
anywhere. It is usually a single lesion, and consists in a 
small, central, bright-red, slightly raised dot from which 
radiate fine red lines. They sometimes become quite large, 
though usually not more than a half-inch in diameter. This 
form is seen in women and children. It occasionally fol- 
lows some slight injury, but very often seems to come 
spontaneously. 

Telangiectases in the form of simple dilated bloodvessels 
of varying size and shape are often seen. Under the same 
heading Crocker places those slightly convex or flat, hemp- 
seed-sized, raised, bright crimson or purplish spots met with 
in old people. Their favorite site is the upper part of the 
trunk, neck, and face. 

Teeatment. The treatment of telangiectasis is simple. 
It is only necessary to introduce the electrolytic needle into 
the red central spot, and turn on a current of about two mil- 
liamperes. The mode of operating is similar to that used in 
destroying superfluous hair, and is described in the section 
on Hypertrichosis. 

Tetter. See Eczema. 

Tinea Amiantacea. See Seborrhcea. 

Tinea Asbestina. See Seborrhoea. 

Tinea Circinata. See Trichophytosis corporis. 

Tinea Cruris. See Trichophytosis corporis. 

Tinea Decalvans. See Alopecia areata. 

Tinea Favosa. See Favus. 

Tinea Furfuracea. See Seborrhoea. 

Tinea Imbricata. Trichophytosis corporis. 



TRICHOPHYTOSIS. 437 

Tinea Kerion. See Trichophytosis capitis. 

Tinea Nodosa. Under this name and that of Leptothrix, 
Paxton's disease, and Trichomycosis nodosa have been 
described cases of parasitic involvement of the hair which 
causes the hair to become brittle and break with a feathery 
fracture, as in trichorrhexis nodosa. Besides this damage 
to the hair, nodular swellings form along the shaft. 
Leptothrix involves the hair of the axillae and scrotum, 
while the name tinea nodosa has been applied to these ap- 
pearances occurring on the whiskers and beard. They are 
doubtless allied to piedra. A somewhat similar disease was 
described by Beigel as due to what he called the " chignon 
fungus." 

Tinea Sycosis. See Trichophytosis barbae. 

Tinea Tondens. See Trichophytosis capitis. 

Tinea Tonsurans. See Trichophytosis capitis. 

Tinea Trichophytina. See Trichophytosis. 

Tinea Versicolor. See Chromophytosis. 

Trichauxis. See Hypertrichosis. 

Trichiasis (Trrk-i 2 -a'si 2 s). This is a congenital or ac- 
quired displacement of the ciliae so that they point backward 
and scratch the cornea. Both lids of both eyes are usually 
affected. The best treatment is the destruction of the hair 
by means of the electrolytic needle, as described in the sec- 
tion upon Hypertrichosis. 

Trichomycose Noueuse. See Piedra. 

Trichomycosis Nodosa. See Piedra. 

Trichonosis Cana vel Discolor. See Canities. 

Trichonosis Furfuracea. See Trichophytosis capitis. 

Trichophytie Circinee. See Trichophytosis corporis. 

Trichophytie Sycosique. See Trichophytosis barbae. 

Trichophytosis (TrPk-o^frVo's^s). A contagious dis- 
ease of the skin and hair, occurring most often in children, 
due to the invasion of the epidermis by the trichophyton 
fungus, and characterized by the formation of circular or 
annular scaly patches, and partial loss of hair. 



488 DISEASES OF THE SKIN. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgment and growth 
on the general cutaneous surface, in the scalp, beard, or 
nails, that is in the epidermic structures. In these different 
localities it develops so differently as to produce very differ- 
ent clinical pictures. We shall describe each one by itself 
and give its differential diagnosis, treating all matters of 
etiology and treatment collectively. 

Trichophytosis Corporis. Synonyms : Tinea circina- 
tus ; Herpes circinatus ; (Fr.) Herpes circine, Trichophytie 
circinee ; (Ger.) Scheerende Flechte ; Ringworm of the body. 

Symptoms. This is the simplest and most readily cured 
of all the forms of ringworm. It begins as a small, pale- 
red, slightly raised spot, which, growing, spreads out into a 
round, sharply defined, scaly patch ; then it clears up in 
the middle, becomes ring-shaped and advances with a raised 
border that may be vesicular ; or crusted from the drying 
of the vesicular contents ; or papular and scaly. After a 
time it either ceases to spread, or, enlarging, the edge of the 
ring becomes broken in places. At last it undergoes spon- 
taneous involution. There may be but a single patch, or 
there may be a number of patches. If two circles meet 
at their peripheries, they coalesce and form gyrate figures. 
Very often rings do not form and w T e have only a round, 
sharply defined, scaly, circular patch. The exposed parts — 
face, hands, and neck — are the most common sites for the 
eruption. In rare cases ringworm may be widely dissemi- 
nated over the body. A slight amount of itching is the 
only subjective symptom, and that may be wanting. 

Another form of ringworm of the body is that known as 
eczema marginatum, which is ringworm located in the crotch 
or axilla. It is usually of a more highly inflammatory char- 
acter than the same disease on other parts of the body, and re- 
sembles an eczema very closely — in fact, it is often compli- 
cated by an eczema. The edge of the patch is sharply 
defined, raised, scalloped, papular, and scaly, while the 
centre may be smooth, or pigmented and crusted. The 
patch often attains large dimensions, running down the in- 
side of the thigh, up over the abdomen, and backward over 



TRICHOPHYTOSIS. 489 

the perineum. Usually the inside of both thighs is affected. 
There is considerable itching. The same symptoms are 
presented when the axillae are affected. 

Tinea imbricata is supposed to be a very aggravated form 
of body ringworm occurring in tropical countries. But 
Manson 1 says that it differs from ordinary ringworm in 
affecting a very large part of the body at the same time ; 
in avoiding hairy parts, and sparing the hair; in an ab- 
sence of signs of inflammation ; in not forming a single 

© ' o © 

ring, but ring within ring, and recurring in parts gone 
over ; in having large abundant scales ; in profuse fungus 
growth ; in always breeding true in inoculation experi- 
ments ; and in occurring only in certain parts of the 
world. 

Diagnosis. Trichophytosis corporis is readily diagnosed, 
as its appearance is distinctive. Favus of the body may 
spread out into a circular patch, but soon it will show the 
distinctive sulphur-yellow cupped crusts. Psoriasis on the 
body will have a brighter red color ; its scales will be more 
abundant, thicker, and brighter : it will be found on the tips 
of the elbows and over the knees, and will be more profuse 
and disseminated ; and examination of the scales will show 
an absence of fungus. The scaling papular syphilide or the 
squamous syphilide will not itch ; there will be no fungus in 
the scales ; the color will be raw-ham ; the base will be 
more infiltrated ; it will run a more chronic course ; and 
will not yield so readily to treatment. Seborrhea of the 
chest may occur in rings, but its location will suggest its 

e. © ' _ CO 

origin ; the skin will be greasy, the scales will rub off easily, 
and there is no fungus in them. Eczema of the crotch or 
axilla differs from ringworm of the same region in not having 

© © O 

a so sharply defined and scalloped or festooned border ; in 
forming a more evenly diseased patch with no sound skin in 
it ; and in having no fungus in the scales taken from it. 
Pityriasis rosea is more widely distributed than is ringworm, 
and spreads more rapidly ; it is not so scaly ; has a more 
yellowish center ; is usually most abundant on the trunk ; 

1 Brit. Journ. of Dermatol., 1892, iv. 5. 
21* 



490 DISEASES OF THE SKIN. 

shows no fungus under the microscope ; and the eruption is 
made up both of macules and rings. 

Trichophytosis Capitis. Synonyms: 1 Herpes tonsu- 
rans, seu circinatus, seu squamosus ; Tinea tonsurans, seu 
tondens ; Porrigo furfurans ; Dermatomykosis tonsurans 
(Kobner); (Fr.) Herpes tonsurante, Teigne tondante ou 
tonsurante, L'herpes circine parasitaire ; (Grer.) Scheerende 
Flechte ; (Slav) Ringskurv ; Ringworm of the scalp. 

Symptoms. This form of ringworm is seen almost exclu- 
sively in infants and children. As puberty or early adult 
life is reached the disease, no matter how long continued, and 
how severe it may be, tends to get well, of itself. It begins 
as a single vesicle or a small, insignificant, red, scaly spot 
that would pass without suspicion of its nature unless other 
cases of ringworm put us on our guard. From this small 
beginning the disease spreads peripherally to form a circular 
patch, which is red, covered with grayish scales, sharply 
defined, perhaps slightly elevated, and partially bald. In- 
spection of the patch will show a number of broken-off 
stumps of hair with split ends. These stumps are char- 
ateristic of the disease. The hair growing in and about the 
patch is dry, lustreless, split, and brittle. Attempts at 
epilation break it off, and if it is indented with the finger- 
nail it will take a sharp angle and retain it. This shows 
that it has lost its resiliency. Apparently healthy hairs are 
sometimes growing from the patch. The size of the patch 
varies greatly. It may be no larger than that of a ten-cent 
piece, or it may be so large as to denude a good part of the 
scalp. These large patches are usually formed by the co- 
alescence of several small ones, and then they lose their 
circular outline and become wavy. There may be but a 
single patch, or there may be a number of them. After 
attaining the size of a half-inch to one inch in diameter, the 
patches may remain stationary in size, or increase slowly. 
The most frequent sites are the vertex and parietal regions. 
Pruritus of greater or less degree is usually complained of, 

1 We can mention here only the more common ones, as their number 
is legion. 



TRICHOPHYTOSIS. 491 

and it may be the first symptom that draws the attention to 
the child's scalp. The course of the disease is exceedingly 
chronic. It does not produce permanent baldness. 

This is the typical "ringworm," as seen in the vast ma- 
jority of cases. Sometimes, instead of being scarcely or 
not at all raised above the surface of the skin, the patch, 
usually a single one, begins to swell up, become raised, un- 
even, and boggy, and we have the condition of things de- 
scribed as kerion (which see). Another variety is what 
Liveing terms "bald tinea tonsurans.'' This begins as an 
ordinary ringworm, but after a time the hair all falls out, 
the scalp is smooth and without scales, as in alopecia areata, 
and at its border there may be found short broken hairs, 
like those seen in the latter disease. At first this change 
takes place in one patch alone, and we will be guided to a 
right diagnosis of the disease by the appearances of the 
other patches. Later, these too become altered, and then it 
would be hard to make the diagnosis without the history of 
there having been scaly patches. This is an infrequent form 
of the disease. 

Still another form is called " disseminated ringworm." 
Here the patchy, areated character of the disease has disap- 
peared, the hair has apparently grown in nicely, and there 
is seemingly only a scurvy condition of the scalp. This is 
a dangerous form, because the child is often regarded as well, 
and yet is quite capable of spreading infection. Careful 
examination of the case, by causing the child to stand with 
his back to the physician, and turning the hair slowly back- 
ward against its direction of growth, will show here and 
there " stumps," and also the presence of hairs that stand up 
from the head for a few moments. Normal hair falls quietly 
and quickly back into place, which is not the case with hair 
affected with ringworm. 

A pustular form is sometimes described. It is simply a 
ringworm occurring in a strumous subject in whom all in- 
flammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. Trichophytosis capitis must be differentiated 
from alopecia areata, favus, eczema, seborrhcea, and psori- 



492 DISEASES OF THE SKIN. 

asis. From alopecia areata it differs in being scaly ; in not 
producing perfectly bald patches ; in its much slower prog- 
ress ; in the presence of " stumps;" and in having the 
trichophyton fungus in the hair, as seen under the micro- 
scope. From favus it differs in the absence of the sulphur- 
yellow cupped crusts of that disease ; in not having such 
heaped up asbestos-like crusts ; in forming distinct round 
patches ; in the more brittle character of its hair ; in not 
producing red, smooth, permanently bald spots that later 
become white and cicatricial, and in showing a marked ten- 
dency to get well of itself as puberty is reached. The diag- 
nosis between them by the microscope is not easy without a 
knowledge of the appearances on the skin. The spores of 
favus are more polymorphous and somewhat larger than those 
of trichophytosis, and its mycelia are more abundant than its 
spores. From eczema it differs in the more circumscribed and 
circular character of its patches ; in being less itchy, and in 
the presence of broken-off hairs and stumps. The presence 
of these broken-off hairs and stumps, and of the fungus in 
the hair and scales will sufficiently distinguish ringworm 
from both seborrhoea and psoriasis. 

Trichophytosis Barbae. Synonyms : Tinea sycosis, seu 
barbae ; Sycosis parasitaria, seu parasitica ; Herpes ton- 
surans barbae; (Fr.) Trichophytie sycosique, Sycosis para- 
sitaire ; (Gr.) Parasitische Bartfinne ; (It.) Sicosi parasitaria ; 
(Eng.) Barber's itch, Ringworm of the beard. 

When the trichophyton invades the beard, at first it forms 
simply a superficial scaly circular patch which increases in 
size, just as on the scalp, producing broken-off hairs and a 
partially bald area. There are usually several of these areas 
upon the chin and cheeks. If not checked by treatment we 
have the more characteristic development of the disease, in 
which there will be either some pustules, pierced by hairs, or 
else a group of large nodular swellings, varying in size from 
a split-pea to a half- cherry, arranged in the form of a circle. 
There are usually several groups of them. The nodules are 
prominently raised and usually rounded. (Fig. 48.) They 
are of a congested red or purple color. They may be 
hard and scaly ; or give exit to a sticky discharge ; or, 



TRICHOPHYTOSIS. 



493 



rarely, suppurate. The hair over them is broken, or more 
or less -wanting. Usually itching and burning are com- 
plained of. 



Fig. 48. 




Trichophytosis barbae. 



Diagnosis. The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. From 
sycosis it differs in affecting the lower part of the face and 
sparing the upper lip ; in presenting broken-off hair ; in 
having grouped nodules ; and in the presence of the fungus 
in the hair. Sycosis is more acute in its manifestations, 
and is characterized by its many discrete pustules pierced 
by hair. From eczema it differs in the same points as it 
does from sycosis and also in being less crusted, and in the 
ease with which the hair can be plucked or will break. 



494 DISEASES OF THE SKIN. 

Eczema is also a disease of the skin and not of the hair. The 
tubercular syphilide does bear a resemblance to trichophy- 
tosis barbae at times. It differs in forming but a single 
group, in being of a darker color, and in undergoing a 
steady course of development toward final recovery, leaving, 
not infrequently, permanent scars. Other symptoms of 
syphilis will often be found, and its whole history will be 
different. 

Trichophytosis unguium, or onycho-mycosis, is ringworm 
as it affects the nails. It begins as a change in color of the 
nail-substance and with a loss of its transparency. The nail 
becomes uneven and thickened, and its edge, which is usu- 
ally the part first attacked, becomes raised from its bed by 
an accumulation of scaly matter under it. A progressive 
atrophy takes place, and at last the nail breaks and falls 
either in part or as a whole. There may be but one nail 
affected, or all the nails both of the hands and feet may be 
attacked, then usually consecutively. 

Diagnosis. The appearances presented by the nails are 
so similar to those seen in psoriasis, and other diseases in 
which the nails become atrophied, that a positive diagnosis 
can be made by the microscope alone, unless there should 
be symptoms of the one or the other disease present else- 
where on the body as a guide. 

Having now described the different varieties of ringworm 
with their differential diagnosis, we pass on to study the fac- 
tors common to all. 

Etiology. The cause of the disease is contagion with 
the trichophyton fungus. This contagion may be direct, 
from person to person, or indirect by means of brushes, 
towels, clothing, and the like. It is possible that the air 
may become so full of the fungus in epidemcs in crowded 
children's asylums that contagion may be by means of the 
fungus lighting upon the head or body. The disease is 
very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and horses, 
constituting in them one form of mange, they form a very 
frequent source of contagion. Ringworm of the scalp is 



TRICHOPHYTOSIS. 



495 



often communicated by means of brushes and headgear. 
Ringworm of the beard is conveyed by means of brushes, 
towels, and the barber's fingers. Ringworm of the nail 
comes from scratching. Some skins seem to furnish a 
better soil for the growth of the fungus than do others. 
Children have ringworm of the scalp ; adults almost never. 
There is no peculiarity of constitution that predisposes to 
the disease. It attacks all classes and conditions of society, 
though, of course, it is most common among the crowded 
poor. 

Fig. 49. 

I » IB » a'| q- . > -. ■ .-, - * . ~ ' -V U : 

^W^--ih- s i 1 :' i h "i ■ i " : = f ■■ ■-' 




4'K 






Trychophyton tonsurans in hair shaft and follicle. (After Kaposi.) 



Pathology. The trychophyton tonsurans, the fungus of 
ringworm, has its habitat in the epidermic structures of 
the skin. On the general cutaneous surface it is so super- 
ficially located as to be readily destroyed. When it 
attacks the hair and nails it penetrates below the skin in 
their epidermic structures, and is much more difficult of 
cure. 

The exact botanical position of the fungus is not yet deter- 



496 DISEASES OF THE SKIN. 

mined, but there is no doubt but that it is a special form of 
fungus. (Fig. 49.) It consists in mycelia and conidia 
(spores), the proportion of which to each other varies ; in the 
hair of the scalp and beard the number of spores far exceeds 
that of the mycelia. Sometimes they are so numerous as to 
be crowded together in lines. On the general surface the 
mycelia are far more numerous. They are long, slender, 
branched, straight, or crooked bodies. The spores are 
round, small, and refract light. Having become lodged in 
the skin the fungus always sets up a certain amount of irri- 
tation by its processes of growth. If it lands upon hairy 
regions it attacks the hair secondarily, passing down the walls 
of the hair follicle to a greater or less depth before it pene- 
trates the cuticle of the hair and gains access to its sub- 
stance. Having gained access, it vegetates freely and may 
often be traced throughout the whole length of the hair. 
Robinson and others have found the fungus in the peri-follic- 
ular tissue. Its presence always causes more or less peri- 
folliculitis, and this is much more intense in the beard than 
in the scalp hair, which, together with the looseness of the 
subcutaneous connective tissue in the beard, will explain 
the reason why we have the nodules form. If the peri- 
folliculitis is very great, permanent baldness may result. In 
trichophytosis unguium the fungus grows in the substance 
of the nails. 

Treatment. — There is no disease of the skin much more 
easy of cure than trichophytosis of the general surface of 
the skin, and none much more difficult of cure than tricho- 
phytosis capitis. 

Trichophytosis corporis may be readily cured with almost 
any slightly irritating and astringent application, and by all 
the antiparasitics. The old women cure it by means of 
common ink, or by using vinegar in which a copper coin 
has been soaked. We can direct that the scales be removed 
with soap and water, and an ointment of sulphur, or am- 
moniate of mercury, or chrysarobin, or pyrogallol be applied, 
or simply paint the patch with tincture of iodine, acetic or 
sulphurous acid, or a solution of bichloride of mercury, three 
to five grains to the ounce. The last is a good method for 



TRICHOPHYTOSIS. 497 

adults, as it does not stain the skin, and one application will 
usually cure the disease. It is rather too. strong for chil- 
dren. Other applications are a solution of hyposulphite of 
soda, two drachms to the ounce ; oleate of copper, half a 
drachm to the ounce of ointment ; and salicylic acid, 5 or 
10 per cent, strength, which by no means exhausts the list. 

Trichophytosis cruris et axillae is not so easy to cure as 
the preceding variety, but it can be cured by any of the 
means detailed above. In using chrysarobin, here as else- 
where, we should bear in mind its irritant qualities. Tay- 
lor has recommended painting the part with two to four 
grains of bichloride of mercury in one ounce of tincture of 
benzoin. Hardaway speaks well of modified Wilkinson's 
ointment. 

Trichophytosis capitis is the most obstinate form of 
ringworm to cure. The fungus is present abundantly 
deep down in the skin, and each hair is a separate focus 
of disease. The difficulty we have to contend against is to 
cause our remedies to enter the skin deeply enough to de- 
stroy the fungus. Nature gives us a hint as to the cure of the 
disease when a kerion forms thai: is not infrequently followed 
by disappearance of the disease. Most of the so-called reme- 
dies for ringworm are irritants to the skin, and do good quite 
as much by the irritation they cause as by their parasiticide 
properties. 

If we see the case at its earliest stage we may sometimes 
succeed in aborting the disease by the application of the 
bichloride of mercury, five or ten grains to the ounce. 
Usually, when the case is brought to us, it has gone too 
far for aborting it. Then we may sometimes cure the case 
promptly, but most often it is an affair of months and, per- 
haps, years. The first requisite for a cure is faith on the 
part of the patient, so that the second element, persistency, 
can come into play ; and then by the persevering use of 
parasiticides a cure may be effected. As each case is a 
source of contagion, steps must be taken to isolate the case 
if it occur in an asylum or school. If it occur outside of an 
institution, the parents must be cautioned not to allow the 
child's hat or clothing to be worn by any other child, and 
the child must be taken out of school. To still further 



498 DISEASES OF THE SKIN. 

assure the safety of others, an antiparasitic must be applied 
to the child's head, such as a 1 or 2 per cent, solution of 
salicylic acid in alcohol and castor oil. The child should 
also wear a linen cap over the whole head. These regula- 
tions are difficult to carry out in private practice. 

The ringworm patch or patches should be scrubbed with 
soap and water so as to remove all the scales before we make 
any local application. Tar soap is a good one to use for the 
purpose. Then the hair should either be cut short, pulled 
from, or shaved off the patches and for about a quarter 
of an inch about them. Now the case is ready for the 
chosen parasiticide. Whatever is used in the form of an 
ointment or oil should not be smeared over the surface, 
but it should be worked in, as it were. The remedies we 
use are exhibited in the form of ointments, oils, varnishes, 
pastes, solutions, and plasters. It is, unfortunately, neces- 
sary to give a lengthy list of remedies from which the 
reader may select. One of the oLlest and most used of 
them is the officinal sulphur ointment, full strength or 
diluted according to reaction. No pustulation should be 
caused by our applications. Here, as elsewhere, when 
an ointment is mentioned, it is to be understood that it 
may be made with lard, vaseline, lanolin softened with 
oil, or plasment (mucilage of Irish moss). The last is to be 
preferred because it is not greasy, sinks readily into the 
skin, and leaves a slight film over the patches that prevents, 
to a certain extent, the escape of the spores into the air. 
The persistent daily use of this ointment, combined with 
epilation, and scrubbing of the patch with soap and water 
about once a week, will cure the disease. Sulphur may also 
be used in combination with other drugs, but as nothing has 
yet been found to render it soluble in any amount, it must 
always be exhibited in ointment or paste form. Mercury 
is another old stand-by. It may be used as a solution of 
the bichloride in alcohol (grs. j-iij ad §j), whose applica- 
tion should not be entrusted to anyone but a physician or 
trained nurse. It is to be used two or three times a day, 
its effect carefully watched, and, of course, it should not be 
used to large surfaces. It maybe employed as recommended 



TRICHOPHYTOSIS. 499 

by Kerley, 1 who reports having cured a number of cases in 
from two to twenty weeks by using a solution made by add- 
ing two grains of the bichloride dissolved in sufficient alcohol 
to a half-ounce each of kerosene and olive oil, daily rubbed 
into patches as well as applied all over the scalp. When 
inflammation is caused, the application is stopped, and a 
simple ointment is used until the irritation subsides. Then 
the bichloride is again applied. The scalp is to be washed 
often. He thinks that a cure will be hastened by using a 
saturated solution of iodine on alternate days with the bi- 
chloride solution. Crocker thinks highly of the bichloride, 
three grains dissolved in alcohol, to the ounce of turpentine. 
Tincture of benzoin is a good excipient for the bichloride, 
according to Leviseur, 2 who recommends the application of 
it, 1 to 2 parts of Hg. to 300 parts benzoin, once a week, 
with the daily use of salicylic acid ointment in 10 to 20 per 
cent, strength. All the mercurial ointments are useful, but 
not so prompt in their action as other remedies. 

The remedies recommended in the treatment of ring- 
worm of the body are all of use in the same disease of 
the scalp, and need not be repeated. The main modifica- 
tion is the epilation that should precede their application. 
Instead of using tincture of iodine, the English authors com- 
mend Coster's paint, made of two drachms of iodine and 
six drachms of the light oil of wood-tar, which is to be 
firmly applied with a stiff brush. A black crust will form 
after two or three days, which should be removed with the 
forceps. The part should then be washed with soap and 
water, and the paint again applied. Two or three applica- 
tions may be made of it to an infant's scalp, or it may be 
continued longer in children over four years of age. 

Chrysarobin in 10 per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis being 
ever borne in mind. Pyrogallol in 5 to 15 per cent, in the 
same excipients, with or without the addition of half a 
drachm of salicylic acid to the ounce, is a reliable prepa- 

1 N. Y. Med. Journ., 1891, liv. 396. 

2 Med. Kec., June 1, 1889. 



500 DISEASES OF THE SKIN. 

ration, fi -naphthol or hydronaphthol are commendable. 
One of the neatest methods for treating ringworm is that 
commended by Dockrell, 1 and it has proved useful in my 
hands. He directs that after shaving and washing the head 
with a 5 per cent, hydronaphthol soap and hot water, the 
part is to be dried and covered with strips of 10 per cent, 
hydronaphthol plaster so that they overlap at the edge. Over 
all is to be poured some melted 10 per cent, hydronaphthol 
jelly. At the end of four days the plaster is to be re- 
moved, the head again washed, and a 20 per cent, plaster 
applied and worn for one week. Finally, a 10 per cent, 
plaster is to be worn for ten days. If not well then, the 
process may be repeated. Naphthol may be used as a 1 per 
cent, solution in alcohol, or in the form of a paste, as recom- 
mended by Kaposi : 2 



R. Naphthol., 

Spt. sap. viridis, 
Alcohol., 


1 

2 
50 


Bals. peruv , 
Sulph. loti, 


2 
10 



M. 

Either may be applied twice a day for two or three days, 
and then followed by thorough scrubbing with green soap. 
Thymol in 5 to 10 per cent, strength, dissolved in chloroform 
and olive oil, is recommended by Malcolm Morris. 

Harrison 3 endeavored to effect entrance of his reme- 
dies to the deeper parts of the skin by first applying to the 
scalp solution No. 1, composed of half a drachm of potas- 
sium iodide in one ounce of liquor potassse. After a few 
days he applies solution No. 2, composed of three grains of 
corrosive sublimate to one ounce of sweet spirits of nitre, or 
of water. This treatment requires careful watching. Foulis 4 
recommends rubbing turpentine into the scalp, after cutting 
the hair, until it smarts. Then it is to be scrubbed with 10 
per cent, carbolic soap, dried, and painted with two or three 
coats of tincture of iodine. When dry the whole head is to 

1 Lancet, 1889, ii., 1110. 

2 Wien. med. Woch., 1881, xxxi. 617. 

3 Brit. Med Journ., 1885, ii. 134. 

4 Ibid., 1885, i. 536. 



TRICHOPHYTOSIS. 501 

be anointed with carbolized oil, 1 in 20. This procedure 
is to be carried out once a day. Alder Smith has found 
useful a saturated solution of boric acid, as follows : 



R . Ac. boric., £iv ; 15 

JEtheris, £ v ; 150 

Alcoholis, ad Jjxx: 600 



M. 



It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

In very chronic cases and in the disseminated form it may 
be necessary to blister the patch by means of croton oil or 
acetic acid. Croton oil must always be used with caution 
and to small areas, as it is capable of producing permanent 
baldness. One part in ten of olive oil is usually suffi- 
cient, but the strength may be increased till we have it 
sufficiently strong to cause a mild degree of pustulation, when 
the hairs may be easily plucked. In disseminated ring- 
worm a drop of the pure oil may be applied to each diseased 
follicle, and as soon as a pustule forms, the hair should be 
pulled out. In very obstinate cases electrolysis may be 
practised to individual hairs, which, like the croton oil, will 
permanently destroy the hair. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths will 
be rendered more open for the entrance of our applications, 
which should always follow epilation. Besnier epilates 
around the patches, and asserts that then the disease rarely 
spreads to neighboring parts. 

Treatment should be continued until there are no more 
stumps or broken off-hairs to be seen ; till the microscope 
fails to reveal any fungus in the hair after prolonged search, 
and until the scalp is no more scaly. It is well to use the 
following — 



H; . Hydrarg, ammon , J) j ; 3 

Hydrarg chlor. mitis, $ ij ; 7 

Vaselini, %] ; 30 



75 
50 
00 M. 



or a sulphur ointment for several months after apparent 
cure. 



502 DISEASES OF THE SKIN. 

Trichophytosis barbae, is treated along the same lines as 
when the scalp is the seat of the disease. The beard should 
not be shaved, but cut short with scissors. Here epilation 
is of more positive value, as the hairs over the nodules will 
come out easily. It is possible to abort the disease before it 
has implicated the hair by the application of a solution of 
five or ten grains of bichloride of mercury in alcohol. A 10 
per cent, solution of resorcin or an ointment of the same 
strength may accomplish the same end. After the disease 
has got under full way, systematic epilation, daily shaving 
by the patient himself, and the thorough application of one 
of the parasiticide preparations mentioned in the preceding 
section will effect a cure. 

Trichophytosis unguium is to be treated by producing a 
paronychia. This may be done by Pelizzari's 1 method of 
keeping green soap upon the nail under a rubber cot for a 
few days, until the nail is softened. Then equal parts of 
olive oil and pyrogallic acid are to be applied till the nail 
loosens, when it is to be removed and the finger dressed with 
iodoform. Thin 2 recommends scraping the affected nails 
very thin, applying liquor potassse to soften them, and then 
dabbing on creasote, or acetic acid, or a solution of two to 
five grains of bichloride of mercury, in alcohol. Crocker 
speaks well of using Harrison's plan for treating ringworm 
of the scalp, which see. Solution No. 1 should be applied 
after scraping and kept on for fifteen minutes, covered with 
oiled silk ; then No. 2 applied in the same way and kept on 
for twenty-four hours. These should be repeated till the 
cure is effected. If the skin should become tender or begin 
to peel, the solutions should be stopped, and one of hypo- 
sulphite of soda used until the skin heals. 

Prognosis. All forms of ringworm, excepting that of 
the general surface of the body, are very obstinate, but 
persevering and intelligent treatment will cure them all. 
The most obstinate form is that of the scalp, and a speedy 
cure should never be promised. 

1 Giorn. Ital. d. Mai. Ven. e del Pelle, March, 1888. 

2 The Practitioner, May, 1887, et seq. 



TUBERCULOSIS VERRUCOSA CUTIS. 503 

Trichoptilose. See Atrophia pilorum propria. 
Trichoptilosis. See Atrophia pilorum propria. 
Trichorrhexis Nodosa. See Atrophia pilorum propria. 
Trichoxerosis. See Atrophia pilorum propria. 
Tubercula Miliaria. See Milium. 
Tubercula Sebacea. See Milium. 

Tubercule Anatomique. See Tuberculosis verrucosa cutis. 
Tuberculosis Cutis. 

Symptoms. This form is a rare one, having been met 
with by Chiari but five times in between 3000 and 4000 
post-mortems, of those who had died of tuberculosis. It 
occurs almost exclusively about the mucous orifices — mouth, 
anus, vulva, and glans penis. Crocker describes the disease 
as follows : " The lesions consist of one or more discrete, 
shallow, not painful ulcers, which form apparently sponta- 
neously, have an irregular, eroded, moderately infiltrated 
edge, and when the crusts, which soon cover them, are 
removed, show a reddish-yellow, granular surface, with a 
thin, scanty secretion. They never heal, but spread slowly 
and continuously, and may coalesce with neighboring ulcers, 
becoming serpiginous ; they may thus extend over an area 
of one or more square inches ; but, as a rule, they are small. 
When on mucous membranes, yellow miliary papules exist 
near them." They are due to local infection with the tubercle 
bacillus, and are a part of a general tuberculosis. Their 
diagnosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the primary 
disease. 

Treatment. Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 

Tuberculosis Verrucosa Cutis. Synonyms : Verruca 
necrogenica ; Lupus verrucosus; Scrofuloderma verrucosum ; 
(Fr.) Lupus sclereux, ou 1. papillaire verruqueux ; Anatomical 
tubercle ; Post-mortem warts. 

These names have been given by different writers to what 
may be regarded as simply varying aspects of the disease 



504 DISEASES OF THE SKIN. 

described by Riehl and Paltauf 1 as tuberculosis verrucosa 
cutis. It is one of the rare skin diseases, but not so very 
infrequent as statistics would show. It was met with four 
times in 3726 cases in Prof. Fox's service at the Yanderbilt 
clinic. 

Symptoms. 2 The disease occurs in the form of one, 
usually, or more patches, which are round or oval ; or, if two 
patches have joined, irregularly shaped, with scalloped 
border, and perhaps serpiginous. In size, the single patches 
vary from that of a lentil up to that of a silver half-dollar. 
Around the patch is a narrow zone of erythema, of a bright- 
red, that disappears under pressure. Its surface is smooth 
and often more shiny than the normal skin. Toward the 
next zone it is slightly elevated. Its follicular openings are 
preserved. 

Inside of this zone is a row of small, discrete, superficial 
pustules, whose covers are so thin that they break easily, 
and we find only the crusts and scales left by them. The 
color of this zone is brown or livid red, and it cannot be 
pressed out entirely, showing that there is some infiltration 
of the skin. This zone is slightly raised, but the one to its 
inner side is markedly so. It has also an irregularly knobby 
surface, becoming distinctly warty toward the centre of the 
growth, the warts being rounded or pointed. The nearer 
the centre the warts are, the larger they are, some of them 
being 5 to 7 mm. long. The whole surface of this zone is 
more or less scaly or crusted. The color is brownish-red. 
The warty growths are often close together with fissures be- 
tween them, and little erosions and pustules. If the patch 
is pinched up between the fingers little drops of pus may be 
made to well up from between the papillae, The mouths of 
the follicles are destroyed. In some cases acute inflamma- 
tion may occur and then the patch will swell up and become 
more angry-looking. 

After a time the patch begins to flatten in the middle by 
the disappearance of the warty growths, and at last becomes 

1 Vierteljahr. f. Derm. u. Sypli., 1886, xiii. 19. 

2 The description here given is taken, for the most part, from the 
above-mentioned article by Kiehl and Paltauf. 



TUBERCULOSIS CUTIS. 505 

changed into a smooth or slightly scaling cicatrix, which is 
thin and soft, with a delicate sieve or net-like appearance. 

The patch is always freely movable upon the underlying 
parts, and usually gives rise to no subjective symptoms. 
Sometimes pain is complained of on pressure. The growth 
is by the addition of new lesions on the periphery of the old 
patch, and is usually very slow, and at intervals, with pauses 
between. It is a chronic affection showing no tendency to 
spontaneous recovery. 

Such is the typical disease and its course. In the de- 
scriptions of the different diseases named above will be found 
some deviations from the type, but they all agree in the 
main, and are probably all one and the same disease. 

Etiology. The cause of this form of tuberculosis is the 
inoculation of the skin with the tubercle bacillus, which has 
been found in sections taken from the patches. The disease 
is seen most frequently in men. and is specially prevalent in 
butchers and those who have to do with animals. Dead- 
house attendants are also its victims, not infrequently. It 
occurs most often on the hands, specially on their backs, 
but may occur anywhere. Cases have been directly traced 
to inoculation with tubercular tissues. 

Diagnosis. Though allied to lupus it differs from it by 
the entire absence of the characteristic lupus tubercles, and 
of a tendency to ulceration ; by the manner of healing in 
the centre ; by a scar in which no relapse takes place ; by its 
superficial situation in the skin ; by the purulent matter that 
can be squeezed out from between its papillae : and by the 
relatively late time of life in which it appears. From syphilis 
it differs in its more chronic course ; in the absence of a wall 
of infiltration about it : in its color ; and in showing no ten- 
dencv to break down and ulcerate. 

Treatment. The growth may be curetted away, and the 
wound afterward treated with pyrogallol, as in lupus. Or 
it may be destroyed by the galvano-cautery. or by electro- 
lysis. Or it mav be covered with a twenty per cent, salicylic 
acid plaster, which Crocker advises to be followed with the 
fuming nitrate of mercury applied with a piece of wood. Or 



506 DISEASES OF THE SKIN. 

it may be destroyed by any powerful caustic, but it must be 
destroyed entirely or it will crop out again. 

Pkognosis. The disease is more readily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumeurs Folliculeuses. See Molluscum sebaceum. 

Tumores Sebiparis. See Molluscum sebaceum. 

Tyloma. See Callositas. 

Tylosis. See Callositas. 

Tylosis Linguae. See Leucoplakia. 

Ulcers. Ulceration is a symptom common to many 
diseases such as lupus, syphilis, scrofulodermata, and other 
destructive processes. For these the reader is referred to 
the sections treating of the diseases of which they form a 
part. We shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological clinic, 
and that are usually called varicose ulcers. They are lo- 
cated most often over the anterior surface of the leg and on 
its lower half. They may be superficial or deep. They are 
irregular in shape with sloping or undermined edges, and 
with a more or less wide zone of redness and infiltration of 
the skin about them. Their bases may be covered with 
flabby granulations ; or smooth and glazed looking with thin, 
scanty secretion ; or they may discharge a great deal of sero- 
purulent matter. Some of them bleed readily, some do not. 
There may be but one ulcer, or there may be several of 
them. One or both legs may be affected. The ulcer may be 
small, or so large as to encircle the leg and occupy more 
than half its length, and it may attain this size either by 
gradual extension of itself, or by the junction of several 
ulcers. They begin not infrequently as a number of small 
shelving ulcers on a red and densely infiltrated base. These 
enlarge rapidly and form a large ulcer. The patient com- 
plains of more or less spontaneous pain, and the ulcers are 
often very tender. The feet and legs are sometimes greatly 
swollen and feel brawny. It will be noted that the foot and 
leg are marked with dilated veins, and varicosities can be 
felt sometimes like whip-cords under the skin. The deep 



(JLCERS. 507 

veins are generally swollen at the same time, though they 
cannot be felt so readily. 

Etiology. These ulcers are predisposed to by standing 
for hours at a time, and it is standing in one position that is 
particularly obnoxious. It is therefore in car-drivers, black- 
smiths, cooks, and those following similar occupations that 
ulcerations are prone to occur. A loaded condition of the 
portal circulation and constipated bowels also favors vari- 
cosities and the occurrence of ulceration. On account of the 
chronic, congested condition of the leg, some slight trauma- 
tism that in the normal state would produce a hardly 
appreciable damage will be followed by a breaking down of 
the tissues and an ulcer. 

Diagnosis. It is most important to diagnose a varicose 
ulcer from one due to syphilis, as they require different treat- 
ment, and have a different prognosis. The syphilitic ulcer 
is usually located upon the upper half of the leg, and toward 
its posterior surface, or about the knee. It has an infiltrated 
border, but by no means as broad a one as the varicose 
ulcer. It lacks the marked inflammatory symptoms of the 
varicose ulcer, and is " punched-out looking " with perpen- 
dicular edges. It is round, or, if formed by the coalition of 
several softened tubercles, it will have a scalloped edge indi- 
cating its origin from several distinct lesions. As a rule, it 
is quite painless, and there are several ulcers on one leg, the 
other being free. 

Treatment. If we can confine our patient absolutely to 
bed, and keep the leg snugly and evenly bandaged, the ulcers 
will heal under simple dressings. This we cannot do with 
most of our cases. Bandaging the leg from the toes to the 
knee is an essential in their successful management, an or- 
dinary roller bandage being used as long as any greasy 
applications are made. In ulcers connected with varicose 
veins, after acute symptoms have subsided, bandaging from 
the toes to knee with a rubber bandage is excellent. So too 
in all ulcers is the continuous bath with warm water, or by 
means of cloths wrung out of hot water, frequently renewed, 
and covered with oiled silk. 

One of the oldest and best treatments for ulcers is to touch 



508 DISEASES OF THE SKIN. 

them up daily with balsam of Peru and cover them with 
oxide of zinc ointment, or, better, with Lassar's paste. Dry 
dressings for the ulcer are preferable to greasy applications, 
and for this we may use iodoform, iodol, aristol, subnitrate or 
subiodide of bismuth, or dermatol, one of the latest remedies. 
If there is any eczema or dermatitis about the ulcer it is 
requisite to cover the powder and the whole patch with some 
mild or stimulating ointment according to the state of the 
skin. In this case the ulcer must be dressed once or twice 
a day. If there is not much dermatitis we can dispense with 
the ointment and do the leg up antiseptically and leave it 
for several days. Applications of nitrate of silver may be 
used to stimulate an atonic ulcer or to smooth down exuberant 
granulations. Strapping with adhesive plaster is another 
excellent means in ulcers upon not very much inflamed 
bases. Skin-grafting according to Thiersch's method is the 
most prompt and sometimes the only way to cause large 
ulcers to heal. For further surgical treatment of ulcers text- 
books on surgery must be consulted. 

Ulcus Rodens. See Epithelioma. 

Ulcus Grave. See Fungous foot of India. 

Ulerythema (U 2 l-e 2 r-i 2 -the'ma 3 ). This is the name pro- 
posed by Unna for those diseases in which there is a more or 
less persistent erythema upon which follows cicatrization by 
a process of absorption of inflammatory infiltration, and 
without ulceration. Under this heading comes lupus ery- 
thematosus. Ulerythema sycosiforme 1 and ulerythema 
ophryogenes 2 are two other varieties of this form of disease . 
They bear a resemblance to the " folliculitis decalvans " 
of the French. They both affect hairy regions, the first 
having a predilection for the beard, and the second for the 
eyebrows. In their course they present symptoms somewhat 
like sycosis, but differ from that disease in causing perma- 
nent bald patches, and the destruction of the skin so as to 
form cicatrices. 



1 Monatshefte f. prakt. Dermat ., 1889, ix , No 3. 

2 Ibid., No 5. 



URTICABIA. 509 

Uridrosis (U 2 r-i 2 d-ro'-si 2 s). Synonym : Sudor urinosis. 
By this is meant the excretion by the sweat pores of sweat 
loaded with the constituents of the urine, specially urea. 
The sweat then often has a urinary odor, and deposits crys- 
tals of urates upon the skin. It is always a complication of 
some grave general disease. 

Urticaria (U 5 r-ti 2 -ka'-ri 2 -a 3 ). Synonyms : Cnidosis ; (Fr.) 
Urticaire ; (Ger.) Nesselsuch, Nesselauschlag, Porcellan- 
friesel ; (Eng.) Nettle-rash, Hives. 

An acute or chronic disease of the skin characterized by 
the appearance of wheals. This usually trivial affection, so 
common as to be a matter of everyday occurrence, at times 
may assume grave symptoms, or entirely nonplus us by its 
persistency. It may run an acute or chronic course. 

Symptoms. The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of a wheal — that is, a firm, flat, circumscribed 
elevation of the skin which is at first pink, and then white. 
They may remain pink. They may be round, oval, annu- 
lar, or elongated, and are always surrounded by a red areola. 
They vary in size, sometimes being no larger than the head 
of a pin, and sometimes of the diameter of an inch. They 
show no tendency to group, but are irregularly disseminated 
over the whole body. Though they are not symmetrical in 
distribution, both- sides of the body are affected at the same 
time, and they show some preference for the extensor sur- 
faces of the arms and legs. They itch, burn, and tingle, 
and are always scratched. They are ephemral, each lesion 
lasting but a short time — from a few minutes to a day. Ex- 
ceptionally some wheals will last several days. New lesions 
crop out as old lesions fade, and thus the eruption is con- 
tinued. The mucous membranes are often affected at the same 
time with the skin ; and if the pharynx should be attacked 
there may be suffocative symptoms. The duration of the 
disease as commonly met with is but a few days, and not infre- 
quently the wheals may be entirely absent during the day, to 
break out again at night. Very often when the patient is seen 
by the physician, he can find nothing but scratched papules. 
But the patient will tell him that when he is undressing, or 



510 DISEASES OF THE SKIN. 

is warm in bed, the itching becomes unbearable, and lumps 
looking like mosquito-bites break out upon him. The skin 
of a patient with urticaria is very irritable, so that a sharp 
tap upon it will produce a wheal. 

The outbreak of the disease may be sudden without con- 
stitutional disturbance, or there may be some burning and 
tingling of the skin before its appearance. Or there may 
be some febrile movement, and some evident disturbance of 
the digestion such as vomiting or dyspeptic symptoms. 
When the disease is cured the lesions disappear without 
desquamation, and leave no trace of themselves. Such is the 
acute form. 

Chronic urticaria differs from the acute form mainly in 
its duration. Instead of recovery taking place in a few days 
or weeks, its course is one of months or years. Sometimes 
the outbreaks of the eruption show marked periodicity, 
coming out at stated intervals after pauses of complete im- 
munity. The eruption is generally not so extensive in 
the chronic as in the acute form. If the itching has been 
very severe and the scratching proportionally excessive, 
the skin may become pigmented, as in other chronic prurigi- 
nous diseases. 

The wheals assume different appearances in different cases, 
and different adjectives are used to express the varying pic- 
tures. It is not necessary to burden the mind with these, 
though they are convenient for descriptive purposes. Thus 
we have urticaria tuberosa seu gigans, where the lesions 
are unusually large ; urticaria bullosa, where the wheals 
are surmounted by bullae ; urticaria hemorrhagica, where 
hemorrhage into the wheals occurs ; urticaria oedematosa, 
probably the same as acute circumscribed oedema, or acute 
angeio-neurotic oedema, where the wheal occurs in locations 
in which the subcutaneous tissues are lax, as about the eye, 
nearly closing it, or on the tongue, causing it to swell enor- 
mously and threaten suffocation ; urticaria papulosa, or 
lichen urticatus, where the wheals are small, a form common 
about the buttocks of children. 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal may 



URTICARIA. 511 

readily be excited by local irritation. Urticaria perstans 
simply refers to the persistent character of the single lesion. 
Urticaria maculosa is the name proposed by Fournier to 
that form in which the wheal remains red. 

Etiology. The causes of the disease are more numerous 
than the forms it may assume. Most of the acute and many 
of the chronic cases are dependent upon irritating ingesta, 
such as shell-fish, strawberries, cheese, pickles, mushrooms, 
pork, sausages, even mutton in some, and almost anything 
in other people, it being largely a matter of idiosyncrasy ; 
medicinal substances, such as quinine, cubebs, copaiba, sali- 
cylic acid, opium, and other drugs. The rupture of hydatid 
cysts has been followed by urticaria. Dyspepsia in its 
various forms, and constipation, are common factors, especi- 
ally in chronic urticaria, as are intestinal worms in children. 
So also at times may be disorders of the liver, uterus, and 
ovaries. Gout, rheumatism, malaria, and functional or 
organic diseases of the nervous system will be found at the 
bottom of many cases of chronic urticaria. 

Not only do we have internal causes producing the disease, 
but also external causes, such as contact with the jellyfish ; 
crawling of caterpillars ; the action of cold, or sudden 
changes of temperature ; the galvanic current ; and bites of 
insects. Urticaria is a common accompaniment of scabies 
and pediculosis. 

Pathology. Urticaria is due to a vasomotor disturb- 
ance. At first there occurs a spasmodic contraction of the 
vessels of a circumscribed area of the skin, which is followed 
by paralytic dilatation of the vessels and retardation of the 
circulation. Serous exudation ensues, forming the wheal, 
which at first is pink, and then becomes white, on account 
of the pressure of the fluid forcing out the blood from the 
central parts of the wheal. When the paresis ceases, the 
serous exudation is absorbed and the part returns to its 
normal condition. 

Diagnosis. The occurrence of wheals is pathognomonic 
of urticaria, as they occur in no other disease. When they 
are present, there is no difficulty in diagnosis. When they 
are not present and we find only scratch-marks we have to 



512 DISEASES OF THE SKIN. 

decide whether we have to do with urticaria or eczema, 
scabies, pediculosis, or dermatitis herpetiformis. Eczema dif- 
fers from urticaria in the tendency its lesions have of running 
together and forming patches. It never could be so generally 
distributed without presenting some characteristic patches. 
Scabies shows scratch-marks on the hands and feet, between 
the fingers and toes, in the axillae, about the umbilicus, and 
on the breasts of women and the penis of the male. The 
cuniculi may be found in most cases. Pediculosis shows 
long parallel scratch-marks over the back, between the 
shoulders, along the outside and inside of the limbs where the 
seams of the clothing come, and about the waist. Dermatitis 
herpetiformis presents grouped lesions, which usually are 
vesicles, but may be papules. Erythema of papular or 
tubercular variety may resemble urticaria, but it is a mark- 
edly symmetrical disease, and burns rather than itches. 

Tkeatment. In acute urticaria the administration of a 
prompt cathartic or saline laxative will usually cure the dis- 
ease if due to some irritating ingesta. Emetics might be 
useful, if we see the case before stomachic digestion is ended, 
but in most cases we are not called in until too late for them 
to be of service. Saline laxatives, mineral acids, rhubarb 
and soda, salol, resorcin, or other intestinal disinfectants are 
of service in the more chronic cases. Of course if the erup- 
tion is due to the ingestion of drugs they must be stopped. 

In chronic cases, beside medicinal treatment we must regu- 
late the diet, studying each case for itself. It is often well 
to put the patient on a strictly milk diet for a few days, and 
then add other articles with care. Alcoholics in all forms, 
and especially beer or other malt liquors, should be pro- 
hibited. If the gouty or rheumatic diathesis is at the foun- 
dation of the trouble, it must be combated. If the out- 
break shows marked periodicity, sulphate of quinine may do 
good. Salicylate of soda sometimes does good service even 
when there is no evident rheumatic tendency. In fact, we 
must endeavor in every way to get our patient into a normal 
state of health. The most difficult class of cases are those 
in which a neurosis alone seems to be the cause. Then bella- 
donna, atropia, arsenic, the bromides, antipyrine, phenace- 



URTICARIA PIGMENTOSA. 513 

tine, and galvanism may be tried. Pilocarpine, wine of 
antimony, colchicum, ergot are also commended In very 
obstinate cases the patient should be sent away from home 
and relieved from all business cares. 

Local treatment is of great service in allaying the itching, 
but it will not cure the disease. The parts may be sponged 
with alkaline lotions, such as a teaspoonful of baking soda 
to a hand-basinful of water. Sometimes more relief is ob- 
tained by an acid solution, such as vinegar, pure or with 
water. Carbolic acid in vaseline, or alcohol and water, is 
sometimes very efficacious. In vaseline, 10 per cent, strength 
is sufficient ; in lotion form we may use, to the adult skin, 
one to two drachms to the ounce, directing the patient to 
dab and not rub it on the skin. Hardaway prefers using 
the acid in a spray, two to four drachms to the pint, with 
one ounce of glycerin. To each atomizerful ten drops of oil 
of peppermint may be added to increase its antipruritic quali- 
ties. Menthol, 1 to 10 per cent, in alcohol or almond oil, 
is said to be efficacious. Crocker speaks highly of liquor 
carb. detergens, 5j to §iv ; terebene, 5iv to §iv ; and equal 
parts of sanitas and water. Salicylic acid, twenty grains to 
the ounce of castor oil, is good, but disagreeable. Camphor 
and chloral hydrate, each from half to one drachm, rubbed 
together and added to one ounce of starch or ungt. simplex, 
is another good antipruritic. Chloroform dabbed on renders 
prompt relief. Baths are sometimes of use. Having the 
patient take a warm bath containing either two to six 
pounds of bran, or a quarter to half a pound of bicarbonate 
of soda, or an ounce of nitro-muriatic acid, just before going 
to bed; then drying his skin by wrapping himself in a warm 
sheet and patting the skin dry ; then smearing the skin with 
a film of vaseline and dredging over this corn-starch powder, 
will often give him a good night's rest. 

Prognosis. — The vast majority of cases of urticaria re- 
cover in a few hours or davs. The chronic cases often are 
most obstinate, but unless some severe nerve lesion is at the 
bottom of the case, they can be cured by patient and perse- 
vering effort. 

Urticaria Pigmentosa. Synonym : Xanthelasmoidea, 

22* 



514 DISEASES OF THE SKIN. 

Symptoms. — This is not an ordinary urticaria that, on ac- 
count of its chronic course and the scratching to which it has 
been subjected, leaves more or less pigmentation of the skin. 
Such a condition of things is not infrequently seen. Urti- 
caria pigmentosa begins within the first six months of life 
by an eruption of wheals or tubercles, which at first are 
about the size of a split-pea, and of a brownish or yellowish- 
red color, with a pink areola. Later, they may increase in 
size, or several may coalesce to form a large one, and assume 
a yellow or buff color. These wheals appear in crops, and 
run a very chronic course, each one persisting for weeks or 
months. They then shrink, become softened, and disappear, 
leaving browish pigmentation. As the course is chronic, we 
will find on the patient wheals or tubercles of red or yellow 
color, of various sizes, some hard and tense, some soft and 
wrinkled, and brown stains of the skin. Ordinary urtica- 
rial evanescent wheals will sometimes be found, and rubbing 
of the apparently stationary tubercles will cause some of 
them to enlarge. The wheals are most often located on the 
trunk and neck ; then on the limbs, face, and head ; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching may or may not be present. After a number of 
years the wheals will no longer come out, and recovery is 
generally complete at about the age of puberty. The major- 
ity of the cases, according to Crocker, occur in boys. We 
know no cause for the disease, and thus far treatment has 
been in vain. 

Vaccinal Eruptions. The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation ; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due not 
to any bad quality of the virus, but either to some accidental 
infection, or to idiosyncrasy. Sometimes an ulcer will form 
at the site of the vaccination ; or starting from this point we 
may have a dermatitis, cellulitis, lymphangitis, erysipelas, 
abscesses, or furuncles. An outbreak of impetigo contagiosa 
may originate from inoculation, the pus of the sore becoming 



VARIOLA. 515 

transferred to other parts by the finger-nails ; or an eczema 
or psoriasis may be set up by the irritation of the sore, just 
as they may follow other affections of the skin. 

General eruptions usually appear, according to Hardaway, 
after the ninth or tenth day of vaccinia, and assume an 
erythematous, papular, or papulo- vesicular character. The 
roseola vaccina of Hebra is an erythematous eruption of 
macular character, commencing usually upon the arms, and 
sometimes spreading over the whole body. It is accom- 
panied in some cases with slight rise of temperature for a 
few hours. It disappears and leaves no trace. 

We may also encounter erythema multiforme and urticaria 
complicating vaccination. It is possible that a bullous erup- 
tion may occur, but this is very rare. Syphilis also may be 
inoculated in arm to- arm vaccination. Gangrene may occur 
in the sore and other accidents. All of these eruptions are 
rare. 

Varicella (Va 2 r-i 2 -se 2 l / la 3 ), or Chicken-pox, is an eruptive 
fever of mild grade, which is characterized by an outbreak 
of a greater or lesser number of clear vesicles, of pinhead 
to pea-size, and varying shape, that come out in crops. A 
long vesicle is very characteristic of this eruption. There 
is usually scarcely any constitutional disturbance. The 
mucous membranes may be involved. 

Variola (Va 2 r-i r o 2 l-a 3 ), or Smallpox, is an acute contagious 
eruptive fever, characterized by very severe prodromal symp- 
toms, such as headache and intense pain in the back and 
legs, and the appearance, usually on the third day, of an 
eruption of minute red spots that soon change into small, 
round, hard, shotty papules. The eruption is first seen on 
the face about the mouth and on the neck and wrists. In 
about twenty-four hours after its first appearance vesicles 
form upon the papules, and attain their full development by 
about the fifth day. They then are umbilicated, are located 
upon a hard base, and have a well-marked areola. Now 
they change into pustules, and a well-marked secondary fever 
attends the change. After about four or five days the pus- 
tules dry up into crusts, and afterward these fall, leaving 



516 DISEASES OF THE SKIN. 

pitted cicatrices in many places. The mucous membranes 
may be involved. 

Diagnosis. Variola bears a resemblance to the pustular 
syphilide; for the differential diagnosis, see the "pustular 
syphilide." Acne and pustular eczema both have lesions 
resembling those of variola, but are limited to certain regions, 
and are not general eruptions. 

Varus. See Acne. 

Vegetation dermique. See Verruca. 

Vegetations. See Verruca. 

Venereal Wart. See Verruca. 

Verbrennung. See Dermatitis ambustionis. 

Verruca (Ve 2 r-ru 2/ ka 3 ). Synonyms: (Fr.) Verrue; (Ger.) 
Warze; Warts. 

These exceedingly common papillary outgrowths assume 
various appearances, to which descriptive names have been 
given. Thus we have verruca vulgaris, or the wart so often 
seen on the hands of children and young people. They very 
in size from that of a hemp-seed to that of a split-pea, or 
larger where two or more become aggregated. They are 
sessile, hard, conical, with flattened tops. They may be 
smooth or uneven, showing their papillary formation. They 
may be of the color of the skin, or some shade of yellow, 
brown, black, or green. There may be a number of them, 
and they may be isolated or aggregated. They may occur 
elsewhere than on the hands. Verruca digitata is applied 
to a wart in which the papillae are separated distinctly from 
each other. They occur in groups, and are often seen on 
the scalp. Verruca filiformis is a wart in which the papillae 
are not only distinct but fine, almost thread-like. Each 
papillary outgrowth stands by itself. They are soft to the 
touch, and occur on the face, eyelids, and neck. Verruca 
plana are flat warts, but slightly elevated, and varying in 
size from a pin's head to a half-inch in diameter. They 
sometimes occur in large numbers. In young people they 
occur upon the face and backs of the hands, and may or may 
not be pigmented. In old people they occur on the back 



VERRUCA. 517 

and arms and are pigmented. In them they are called 
verruca senilis, or seborrhceal warts. Verruca acuminata, 
also called condyloma acuminata, vegetations dermiques, 
spitzen warzen, and venereal or moist warts, are met with 
in the anal and genital regions of both sexes, as also in the 
axillae, under the hanging breasts, in the umbilicus, and 
between the toes. They are vascular, sessile or pedunculated, 
and composed of a great number of closely aggregated pro- 
jections of various shapes. On exposed situations they are 
dry and of the color of the skin ; while in locations that are 
moist — that is, between skin folds — they are covered with a 
whitish puriform secretion, and, unless kept very clean, they 
emit an offensive odor. They sometimes attain to an im- 
mense size. 

Etiology. We do not know the cause of warts. They 
are regarded by some as contagious, and parasites have been 
isolated and declared to be the morbific agents. They 
occur more frequently in the young than in the old, and 
may be congenital. Verruca acuminata are traceable to 
irritating discharges, but not by any means always to a 
gonorrhoea. 

Treatment. The treatment of most all warts is prompt 
and efficient by means of the currette, scraping them off 
while the skin is slightly stretched. If there is any doubt 
about their returning, their bases may be touched with 
iodine or nitric acid. Generally simple scraping is suffi- 
cient. Electrolysis may be used. The digitate and filiform 
warts may be snipped off with the scissors, but this presents 
no advantage over the curette. If operative interference is 
refused, the warts may be removed by painting with tinc- 
ture of iodine ; or a saturated solution of salicylic acid ; or a 
20 per cent, solution of resorcin ; tincture of thuya ; or 
nitric or glacial acetic acid. In the country, children's 
warts are removable in some cases by the application of 
the juice of the common milk-weed. Acuminate warts may 
be removed by keeping them clean and dry, and painting 
them with liq. plumbi subacetatis, or a solution of the 
perchloride, or persulphate of iron ; or dusting them with 
salicylic acid and starch, or boric acid. Chromic acid is a 



518 DISEASES OF THE SKIN. 

powerful caustic. Caustic potash is not a safe one to use, 
unless care is had to limit its action by a ring of wax about 
the wart. The galvano-cauterj may also be employed. 

It is said that warts may be removed by internal treatment. 
Sulphate of magnesia, two or three grains to a child and 
half a drachm to an adult, three times a day, is one remedy. 
Besnier has tried this method in a number of cases with ab- 
solute unsuccess. Tincture of thuya occidentalis, two or 
three times a day, is said to be efficacious. Crocker thinks 
he has seen cures effected with full doses of nitro-muriatic 
acid. 

Warts very often disappear of themselves, and no one has 
ever seen them fall. 

Verruca Necrogenica. See Tuberculosis verrucosa cutis. 
Verrue. See Verruca. 
Verrugas, Endemic. See Yaws. 
Vibices. See Purpura. 
Vitiligo. See Leucoderma. 
Vitiligo Capitis. See Alopecia Areata. 
Vitiligoidea. See Leucoderma. 
Wart. See Verruca. 
Warze. See Verruca. 
Warzenkrebs. See Carcinoma. 
•Warzenmal. See Nsevus verrucosus. 

Washleather skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. It 
occurs, as a rule, in patients suffering from diseases which 
directly or indirectly affect either the trophic or the sensory 
nerves, such as renal disease, phthisis, erysipelas, and 
hemiplegia. It sometimes precedes the occurrence of bed- 
sores. 

Weichselzopf. See Plica. 
Wen. See Sebaceous cyst. 
Whelk. See Acne. 
Xanthelasma. See Xanthoma. 



XANTHOMA. 519 

Xanthoma (ZaVthc^ma 3 ). Synonyms : Xanthelasma ; 
Vitiligoidea ; Molluscum chol6sterique ; Fibroma lipoma- 
todes. 

A peculiar disease of the skin characterized by the ap- 
pearance of discrete patches, or tubercles of chamois or 
lemon-yellow color. 

Symptoms. Xanthoma may assume one of two forms : 
Xanthoma planum, or Xanthoma tuberosum or tuberculatum. 
In the former we meet with flat, chamois-leather, or lemon- 
yellow plates that are either slightly raised above the level 
of the skin, or not at all raised. They vary in size from an 
eighth of an inch to an inch in their long diameter, feel soft 
and smooth to the touch, and when pinched between the 
fingers no infiltration of the skin is perceptible. They are 
irregular in shape, tending to form elongated figures. When 
in patches they feel almost velvety, and when examined with 
a lens thev are seen to consist of an aggregation of small 
granules, many of which have a central pinkish punctum. 

Xanthoma tuberosum exhibits lesions of the same color 
as does the plain variety, or they may be of reddish-yellow, 
but they are raised above the skin and may attain to a large 
size. They are soft, smooth, round, or oval, with telan- 
giectases over them when small. When large, they are firmer 
and more irregular in shape, being made up by aggregation 
of a number of smaller tubercles. Xanthoma multiplex is 
the name applied to cases in which both varieties are present. 
In all forms, unless there is jaundice, the skin between and 
about the lesions is normal in color, Most cases give rise 
to no subjective symptoms, but there may be some itching 
or burning. If the disease occur upon the palms or knees it 
may cause discomfort or even pain on kneeling or handling 
objects. 

The favorite seat of xanthoma planum is in the upper 
eyelid, where they are not infrequently seen. They there 
commence at the inner canthus, most often of the left eye, 
and spread in a semicircle about the eye, while shortly after- 
ward a similar growth begins on the right upper eyelid. 
Next in point of frequency to the eyelids, they occur upon 
the flexures and mucous membranes. Xanthoma tubero- 



520 DISEASES OF THE SKIN. 

sum is most frequently seen upon the knees, elbows, 
knuckles and other points of pressure, the trunk being not 
so much affected. Symmetry is generally observed. Xan- 
thoma multiplex is often very widely distributed. Some- 
times the lesions run in streaks, or, as in Hardaway's case, 1 
are arranged like a zoster. The following case reported by 
me 2 is one of the most extensive on record. 3 

Michael M., aged five years, was admitted to my service 
at the Randall's Island Hospital in May, 1890. From 
the child's sister I have been able to gather the following 
imperfect history : The eruption appeared when the child 
was three months old, without any antecedent disease, 
and came out all over the body at the same time. It is 
thought that no new lesions have appeared since then ; 
that there has been no change in the size of the lesions, and 
that some of them have disappeared. The boy is said to 
have always been well, to have played about like other boys, 
and never to have been jaundiced. 

Examination of the boy reveals a very extraordinary con- 
dition of affairs : The whole body of the boy is occupied by 
a disseminated efflorescence, no part being spared except the 
hands, feet, and scalp. The lesions are about the size of a 
split-pea, or a little smaller, are soft to the touch, and have 
a central depression. Upon the face, trunk, shoulders, and 
lower part of the legs they are discrete, and scattered about 
without any particular arrangement. Upon the extremities 
the lesions are crowded into patches of various sizes and 
shapes, with normal skin between them. Even in the patches 
the lesions are distinct. They touch each other but do not 
coalesce. The distribution of the lesions and of the patches 
is quite symmetrical. The color varies from a lemon-yellow 
in the discrete lesions on the shoulders to an orange-yellow 
in the patches. About the joints the color is reddish-brown. 

In the right eyelid are well marked, typical xanthomatous 
patches of a chamois-leather color. The lower lid is occupied 

1 St. Louis Courier of Med., October, 1884. 

2 Journ Cutan and Gen.-urin. Dis., 1890, viii. 241. 

3 See frontispiece for illustration. 



XANTHOMA. 521 

by one continuous patch, running from the inner to the outer 
canthus. On the upper lid there is a small tumor. The 
left lid is but very slightly affected. Upon the back of the 
neck and the upper part of the back are a number of light- 
brown pigmentary spots, which the sister says are the re- 
mains of some lesions that have disappeared. Scattered 
about the trunk are a number of depressed scars, apparently 
the remains of a recent varicella. 

The boy is very thin, of blonde type, and the skin is pale. 
Apart from this there is nothing abnormal. His appetite is 
good, his digestion is in fine condition, and his urine con- 
tains neither albumin nor sugar. Upon the left buttock 
there is one vascular nsevus. 

The skin in Xanthoma is not alone affected. Xantho- 
matous bodies are found in the liver, mucous membranes, 
and tendons. The disease is progressive for a time, and 
then may remain stationary for years, or may undergo spon- 
taneous resolution. 

Etiology. Xanthoma occurs much more frequently in 
adults than in children, and that form that occurs in the 
eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the 
disease is sometimes hereditary. But we really do not know 
as yet what is the cause of the disease, though various theo- 
ries have been advanced. Hepatic diseases ; diabetes ; dia- 
thetic conditions of various kinds ; migraine ; embryonic 
cells left in the skin ; each have been found in connection 
with one or many cases. Hardaway may not be wrong in 
his idea that it is a diathetic disease, and that when it occurs 
with jaundice it is because the same tubercles have been 
deposited in the liver as in the skin, and the jaundice is 
secondary to them. 

Diagnosis. The diagnosis of this unique disease is made 
by the occurrence of chamois-leather-colored soft plates or 
tubercles, such as occur in no other disease. 3Iilium may 
bear some slight resemblance to xanthoma, but it is hard 
and firm, not soft and velvety, and white, not yellow. It 



522 DISEASES OF THE SKIN. 

is easily squeezed out after a prick through the skin over 
them, an impossibility in xanthoma. 

Treatment. In the way of treatment we have no sure 
resource save the knife and electrolysis. The latter is the 
more preferable of the two. In so general a case as mine, 
neither plan would be applicable. Besnier 1 reports good re- 
sults from the administration of phosphorus in cod-liver oil, 
giving one milligramme per day, and increasing the dose 
each day by a quarter of a milligramme until three milli- 
grammes are taken. After fifteen days this is stopped and 
turpentine is given. Stern 2 tried this plan without success, 
but succeeded in removing patches of the disease from the 
eyelids by the use of a ten per cent, solution of corrosive 
sublimate in collodion. 

Xanthoma Diabeticorum. Besides the xanthoma just de- 
scribed there is another form which is regarded by many as 
a distinct affection, and called Xanthoma diabeticorum. 

Symptoms. It is an exceedingly rare disease, which dif- 
fers from ordinary xanthoma in its more sudden develop- 
ment ; in disappearing sooner or later, perhaps to recur ; by 
the hardness of its lesions, which are never macular ; by the 
frequent absence of a yellow color ; by the presence of a cer- 
tain amount of inflammation ; by absence of jaundice, and 
presence of diabetes mellitus ; by its more pruriginous char- 
acter ; by avoiding the eyelids ; and by having its lesions 
about the mouths of the hair follicles. In fact, it resembles 
ordinary xanthoma mostly in its location upon the elbows, 
knees, and other points of pressure, and in the general con- 
figuration of the lesions. The treatment should be directed 
to the diabetes and to the allaying of the itching. 

Xeroderma. See Ichthyosis. 

Xeroderma Pigmentosum. See Atrophoderma pigmen- 
tosum. 

Yaws 3 (Ya 4 z). Synonyms : Framboesia ; Pian ; Parangi ; 
Verruga. This is a disease that occurs only in tropical 

1 Journ. de Med et de Chir., April, 1886. 

2 Berlin klin. Woch., 1888 xxv. 393 

3 This account is condensed from Crocker. 



ZOSTER. 523 

countries. The stage of incubation lasts two to eight weeks 
and without special symptoms. The stage of invasion, with 
more or less well-marked fever, which abates before the 
eruption, lasts one or two weeks. The eruption is preceded 
by enlargement and tenderness of the lymphatic glands, and 
consists of pinhead to lentil-sized, slightly elevated papules 
on a broad base. The papules enlarge, the epidermis splits 
and curls off from their centres and exposes a yellowish 
point which develops into a flat, moist, red, or pink 
tumor, looking not unlike a raspberry. These tumors 
range in size from a split-pea to a nut, are round or 
oval, discrete, or coalesced into large, irregular masses. 
The surface of the tumor is covered with a thin, yellow- 
ish, foul-smelling discharge, that dries into scabs, which 
may ultimately form rupia-like crusts. In the mouth 
and in moist situations no crusts form, and the tumors will 
resemble mucous patches. They reach their full develop- 
ment in from two to four weeks, remain stationary for months, 
and then dry up and fall off, leaving a spot on the skin 
that eventually disappears. They may break down and 
ulcerate, involving both the adjacent soft parts and the bones. 
The tumors are not tender. The disease tends to recovery, 
but is subject to relapses. Death occurs in bad cases. It 
is contagious, and one attack is protective to a certain 
extent. 

Treatment. The treatment is hygienic and by tonics. 
Locally, disinfectant applications should be used. 

Zaraath. See Lepra. 
Zona. See Zoster. 

Zoster (Zo 2 st/u°r). Synonyms : Zona ; Herpes zoster ; 
Ignis sacer ; (Ger.) Feuergiirtel, Giirtelkrankheit ; Shingles. 

An acute disease of the skin characterized by a unilateral 
eruption of groups of vesicles upon reddened bases scattered 
along the course of certain nerves. 

Symptoms. Zoster, like psoriasis, presents such marked 
lesions that once seen it is readily recognized when seen 
again. It occurs in the form of groups of vesicles seated 
upon red bases, and arranged along the course of nerves 



524 



DISEASES OF THE SKIN. 



upon which there are ganglia. (Fig. 50.) The vesicles are 
at first filled with serum that afterward may become cloudy. 
They do not tend to break down of themselves, but are fre- 
quently ruptured by accident. The size of the groups 
varies greatly. There may be but a few vesicles or a large 
number of them closely crowded together. Sometimes a 



Fig. 50. 







Zoster, of arm. 



group is no larger than a three-cent piece, and sometimes it 
is several inches in its longest diameter. Sometimes the 
vesicles may run together and form blebs. The shape of 
the groups is always irregular. There may be but two or 
three groups or a score of them. In nearly all cases the 
disease is unilateral, though it is not uncommon for one or 
two groups to be found close to the middle line, on the side 
opposite to the site of the disease. All the groups do not 
come out at once, but, as it were, by a series of outbreaks, the 
earliest ones to appear usually being those nearest the point 
of exit of the nerve. The eruption is usually at its height 
in a week, the vesicles drying up, forming a crust and fall- 
ing off, leaving a red mark that soon fades. The whole 
duration of the disease is from ten days to three or four 
weeks. 

In many, if not most cases, the patient experiences neu- 
ralgic pain in the nerve along whose course the eruption is 
about to appear. This is sometimes wanting, and generally 



ZOSTER. 525 

lessens or disappears when the eruption appears. Some- 
times the pain is severe during the duration of the eruption, 
and after it is gone. Tender points may often be found over 
the points of exit of the nerves, just as are found in neural- 
gia. In some patients there will be fever before the out- 
break of the vesicles or the successive appearance of new 
groups. The vesicular stage is preceded by an erythemato- 
papular stage. Very rarely some of the groups may 
abort at this stage. Exceptionally, zoster may occur on 
both sides of the body. In nearly all cases the disease does 
not recur. Exceptionally, a patient may have several at- 
tacks of the disease. 

Most cases of zoster occur upon the trunk, and, it is said, 
specially on its right side. It also occurs upon the face, on 
branches of the fifth nerve when it may involve the eye. 
The neck may be affected, and with it the arm. The leg, 
too, may suffer. Generally, the eruption does not reach 
further down than the elbow 7 and knee, though it may occupy 
the forearm and hand, leg and foot. In rare instances, the 
tongue and pharynx may be affected. Various names are 
used to designate the location of the eruption, such as zoster 
frontalis, ophthalmicus, cervicalis, intercostalo, genito-crural, 
and the like. 

In rare cases hemorrhage may occur into the vesicles, or 
they may be purulent from the start, or they may ulcerate 
or become gangrenous. The neuralgia may continue in old 
or debilitated subjects in so severe a manner as to threaten 
the exhaustion of the patient from pain and loss of sleep. 
Or pruritus, hyperesthesia, or anaesthesia may be left for 
some time after the disappearance of the eruption. Or 
paralysis of motion may./ollow the attack, as well as atrophy 
of muscles. Scars will follow the disease if ulceration has 
occurred. 

Etiology. Zoster occurs more often in children than 
adults. Sex seems to have little influence. It follows upon 
injuries to nerves in some cases, and has been associated 
with caries of the ribs. It has been known to occur while 
the patient was taking arsenic. Jt occurs frequently in the 
damp cold weather of the spring and autumn, so much so as 



526 DISEASES OF THE SKIN. 

to give rise to epidemics. Indeed, some regard the disease 
as infectious on account of the epidemic character it some- 
times has. Some cases seem to arise from peripheral irri- 
tation of cutaneous nerves. A descending peripheral neuritis 
of the spinal ganglion is regarded by Crocker as the condi- 
tion most frequently associated with the disease. In a great 
number of cases, disease of the ganglia upon the posterior 
roots of the spinal nerves has been found post-mortem. 
When the fifth nerve is affected, it is the Gasserian ganglion 
that is diseased. 

Diagnosis. Zoster in most cases is readily recognizable. 
It differs from eczema in having larger vesicles that do not 
tend to rupture ; in its patchy character, the patches being 
located along certain nerve trunks ; in the neuralgia that ac- 
companies it ; and in the definite course that it runs. Herpes 
facialis or preputialis sometimes resembles zoster quite 
closely, but in them there will often be a history of previous 
attacks ; they will not occur so markedly as groups of 
vesicles upon one side alone ; and they will not be preceded 
by the same amount of neuralgia. By some authorities 
herpes and zoster are considered to be the same disease. 

Treatment. The most important part of the treatment 
of zoster is to prevent the breaking of the vesicles, and the 
possible ulceration that would follow and leave scars. To 
this end we should avoid ointments and use dusting powders, 
such as oxide of zinc, or bismuth, or starch, or, what is 
better, we should paint the vesicles with flexible collodion 
with or without morphia, which sometimes seems to abort the 
formation of vesicles. It is also advisable to cover the erup- 
tion with a soft linen bandage to prevent rubbing. If the 
vesicles have become broken and ulceration has ensued, then 
we have to treat the ulcers on surgical principles. 

To relieve the pain of zoster the galvanic current gives 
the best results, one sponge electrode being placed over the 
spine, and the other passed around the groups for ten or 
fifteen minutes once or twice a day. A current strength of 
two or three milliamperes may be used, and, if it can be done, 
the last application should be made just before going to bed. 
Other means are hypodermatics of morphia ; blistering over 



ZOSTEK. 527 

the root of the nerve ; and the use of the menthol cone or 
oil of peppermint. Phosphide of zinc, one-third of a grain 
every three hours, is thought by some to relieve the pain 
and limit the eruption. For the persistent neuralgia that 
at times follows these cases, arsenic, or strychnia, iron, 
quinine, cod-liver oil, and a good nutritious diet are neces- 
sary. Opium may have to be given to allay pain and pro- 
cure sleep. 

Prognosis. Most cases of zoster run a favorable course 
and get well of themselves. It is only in old or debilitated 
people that we need fear any serious results. There is 
always the possibility of the occurrence of ulceration and 
gangrene, though it is not to be expected in the vast majority 
of cases. The popular opinion that if zoster occurs on 
both sides at once and forms a girdle, the patient will die, is 
not borne out by the facts. 



APPENDIX. 



The following formulae are given as guides in the preparation 
of prescriptions for the treatment of skin diseases. Many, if not 
all of them, have been well tried and their value proved : 

A. BATHS. 



Simple Water Baths: 




Cold . 


. 40° - 65° F 


Cool . 


. 65°-75°F 


Tepid . 


. 85°-95°F 


Warm 


. 95°-100° F 


Hot . 


. 100°-110° F 



Wet Pack. Wrap patient in wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry, and anoint 
with oil or ointment. Useful to remove the scales in psoriasis, and 
to diminish hyperemia. 

Medicated Baths. To an ordinary bath-tub-full, say thirty gallons 
of water, add for 

2 to 6 lbs. bran. 



Bran bath 
Potato-starch bath 
Gelatin bath 
Linseed " 
Marshmallow bath 
Size bath 



1 lb. starch. 

1 to 3 lbs. gelatin. 

1 lb. linseed. 

4 lbs. marshmallow. 

2 to 4 " size. 



These baths are useful in erythematous, itchy, and scaly diseases. 

To bath. 
Bicarbonate of soda bath . . 2 to 10 ounces. 

Carbonate of potassium bath . . 2 to 6 " 
Borax bath ..... 3 " 

These baths are useful in eczema, psoriasis, urticaria, prurigo, and 
pruritic diseases. 

To bath. 

Nitric acid bath ..... 1 ounce. 
Muriatic acid bath . . . . . 1 " 
Or may use of each . . . . . J " 

Of use in chronic pruritic diseases. 

23 



530 



APPENDIX 



Iodine Bath 



Iodine 

Iodide of potassium vel 

Liquor potass. .... 

Glycerin ..... 

Useful in scrofulous and squamous diseases. 



To bath. 
2- to 1 drachm. 

j ounce. 
1 to 2 ounces. 
2 " 



Bromine Bath: 

Bromine . 

Iodide of potassium 

Same indications as iodine bath. 



Potass, sulphuret 
Used in scabies, chronic eczema, lichen, and psoriasis. 



To bath. 
20 drops. 
2 ounces. 



To bath. 

2 to 4 ounces. 



Startin's Compound Sulphur Bath : 

To bath. 
Precipitated sulphur ... .2 ounces. 
Hyposulphite of soda ... .1 ounce. 
Dilute sulphuric acid . . . • i " 
Water 1 pint- 
Same indications as the sulphuret of potassium bath. 



Mercurial Bath: 

Bichloride of mercury 

Hydrochloric acid . 

Water 

Used in pityriasis rubra and the syphilides. 



To bath. 

3 drachms. 
1 drachm. 
1 pint. 



. B. INTERNAL USE. 

1. Turpentine Emulsion: 

J£ . 01. terebinthinae, 1TLx-xxx ; 0.66-2 

01. limonis, TTLij ; 1 

Mucilag. acacise, ^ss; 16 

Aquae, E ss ] 16 M. 
Sig. A teaspoonful three times a day immediately after meals. 
One quart of barley water to be drank during twenty-four hours. 
(Crocker.) 

Used in psoriasis, eczema, and hyperemias. 



APPENDIX. 



531 



2. Mixed Treatment: 

a. R . Hydrarg bichlor., gr. j-iij ; 

Potass, iodid., ^iv-viij; 16-32 

Tinct cinchon. co., Jf iijss ; 112 

Aquse, % ss ; 16 



06-.2 



M. 



Sig. One drachm in water t. i. d one hour after meals (Taylor.) 

b. R. Hydrarg. biniod , gr. ss-ij ; [03— .13 

Ammon. iodid , 
Potass, iodid., 
Syr aurant. cort., 
Tinct. aurant. cort , 

Aquse, ad % iij ; 100 M 

Sig. One- half ounce t. i. d after meals. (Keyes ) 



gr. ss-ij ; 




3ss; 


2 


3y-3j; 


8-32 


Ijss: 


48 


sj; 


4 


ouj; 


100 



c. R. Hydrarg. bichlor. vel ) o> , ... # 
Hydrarg biniod., j *> - J J > 
Potass, iodid., 3J - ij 5 



Inf. gent. co. vel \ 

Syr. sarsaparillse co., J £ 

Sig One drachm t. i. d. after meals. 
These three are used in syphilis. 



IV 



4-8 
128 



06-. 13 



M. 



3. R . Gurjun oil, % j ; 
Liquor calcis, % iij ; 


33(33 
100 1 


M. 


Sig. One-half ounce twice a day. 






Used in leprosy. 






4. R . Tinct guaiaci, TTLxl ; 
Tinct aconiti, TlXij ; 
Aq. camphorse, ,^ss; 


2 
16 


66 
13 


M. 


Used in chronic skin diseases, specially with 
Fox.) 


rheumatic 


taint (T 


5. R. Tinct. cannabis indicse, Tltx-xxx ; 
Pulv. tragacanth. co. gr. x ; 
Aquse, § j ; 


0.66-2 
32 


m 


M. 


Used in pruritus and prurigo. (Bulkley.) 






6. Startin's Mixture: 






R . Magnesii sulphat., 3 v j _x ij j 
Ferri sulphat., gj ; 
Ac. sulphur, dil., % ij ; 
Syr. pruni virgin., % j ; 
Aquse, ad % iv ; 


20-30 

3 

6 

24 

100 




M. 



Sig. One drachm t. i. d after meals, through a tube. 






532 



APPENDIX. 



M. 



7. Asiatic Pills: 

J&. Ac arsenici, gr. lxvj. 

Pulv. pip. nigrse, ^ix. 

Gum Arabic. 1 

Aqu*, } aa * 8 " 

Div. in pil. no. dccc. 

Sig. One to three pills a day after meals and increase to toler- 
ance. 

Used in psoriasis. 

8. R. Pil. hydrarg., J}ij ; 2 

Ferri sulphat. exsic., £)j ; 1 

Ext opii, gr. v ; 33 M. 

Div. in pil. no. xl. 

Sig. One t. i d. (Taylor.) 

Used in syphilis. Sulphate of quinine may be substituted for the 
iron. 



9. H. Hydrarg. ch lor. mitis, gr. jss ; 

Ferri lactatis, gr. iij ; 

Sacch. alb., gr. xv ; 

Ft. in pulv. no. x. 

Sig. One to four daily. (Monti.) 

Used in infantile syphilis 



M. 






C EXTEKNAL USE. 

a. Caustics. 
1. Cosme's Paste : 

j$ . Ac. arseniosi, gr. x ; 

Hydrarg. sulphuret. rub., 3 ss ; 

Ungt. rosse vel \ z 

Sacch. alb., / ^ ' 

To destroy epithelioma or other new growths. 



2 
16 



m 



M. 



2. Marsden's Paste : 

R . Pulv. ac. arseniosi, 
Pulv gum acacise, 



^ 3j; 



M. 



Mix with water to form a paste just before using, and apply to not 
more than one square inch at a time. 
Same indications as last. 



APPENDIX. 533 

3. Bougard's Paste : 

R. Wheat flour, \ -- fi0 , 

Starch, / aa b °P arts ' 

Arsenic, 1 part. 

Cinnabar, ) > . 

a i ' • V aa 5 parts. 

Sal. ammoniac, J ^ 

Corrosive sublimate, ^ part. 

Sol. chlor. of zinc @ 52°, 245 parts. M. 

Grind first six ingredients to a fine powder, then mix them in a 
mortar Add solution of acid, slowly stirring. Keep in earthen jar. 

Sig. Apply accurately to part ; keep on for thirty hours ; follow 
with poultice. 

4. Depilatory Paste : 

R . Barium sulphid., 5 ij ; 8 

Zinci oxidi, ) - , . _ . • . -, 

Amyli, } aa 3 n J' 12 M> 

Make into a paste with water and apply a thin coating for ten to 
fifteen minutes, then clean off and apply a bland ointment. 

5. Salicylic Acid (Crocker) : 

R. Glycerini, £ j ; 321 

Ac. salicyl., q. s ; M. 

Make in consistency of thick cream. To lessen painfulness of appli- 
cation may add 



R. Ac carbolici vel \ • , a 

Creasote, J ^ ' 

Used to destroy warts, lupus, and epidermic thickenings 



M. 



6. Vienna Paste, 

R. Calcis, 

Potassse. 



V aa p. se. M. 



Make into a paste with alcohol just before using 
Used in lupus and scrofulides. 

7. Canquoi?i's Paste : 

R. Zinci chlor., 1 aa zi • 4 

Ammon. chlor., f c '^ J ' 
Pulv. amyli, 3 jss ; 6 

Aquse, q. s. : 

Make into a paste at time of using. 

Used to destroy lupus, epithelioma, and the like. 



M. 



534 



APPENDIX. 



8. Middlesex Hospital Paste. 

K • Zinci chlor., \ 
Liq. opii sed , J 
Amyli, 
Aquae, 

Same indication as last. 

9. R • Zinci nitrat., 

Bread mass, 

Mix before using. 



Sjss ; 

3j; 



6 
32 



1 part. 

2 parts. 



M. 



M. 



b. Lotions. 



1. Belladonna Lotion 



Be . Tr. belladon , ) 
Glycerini, j 
Aquae, 

Sig. For erysipelas. (Piffard.) 



aa 1 part. 
8 parts. 



M. 



2. Bismuth Lotion : 

B • Bismuth, subnitrat., gr. vijss ; 

Zinci oxidi, 3 ss ; 

Glycerini, Tttxv ; 

Hydrarg. bichlor., gr. \ ; 

Aquae rosae, ^j ; 

For rosacea and hyperaemic conditions. 

3. Calamine Liniment : 

B . Pulv. calamine, 9 ij ; 

Zinci oxidi, 3 ss ; 

Carron oil, %] ; 

For erythema, eczema, and hyperaemic conditions. 

4. Calamine Lotion : 

R. Pulv. calamine, 
Zinci oxidi, 
Glycerini, 
Aq. rosae, 

For erythema and eczema. 

5. Carbolic Acid Lotion : 

Jjt. Ac. carbol., 



Alcohol., \ 



Aquae 
!Sig. For erysipelas. (White.) 



3j; 

aa Oss ; 



2 
1 

32 



2 

2 

32 



016 



M. 



66 



M. 



By; 


2 


£ss; 


2 


Wxv; 


1 


Zr, 


32 



66 



M. 



4 
250 



M. 






APPENDIX. 






6. Carron Oil : 








R. Aq. calcis, 1 
01. olivaa vel >- 
01. lini, J 
For burns. 




Equal 


parts. 


7. Coster's Paint: 








R. Iodine, 

01. picis liquidae, 




3 i-ij ; 
3J; 


4-81 
30 


8. Fox's C. C. C. Mixture : 








R . Chrysarobim, ^ 
01. cadini, J 
Ac. carbolici, 
Ac. oleici, 




aa 2 

1 
50 


parts. 

part, 
parts. 


Sig. In psoriasis. 








9. Hardaway' s Lotion for Li 


chen 


planus : 




R . Sapo. olivae prep., 
01. rusci, \ 
Glycerini, J 
01. rosmarini, 
Alcoholis, 


aa 

ad 


7, jss ; 
5 v"j ; 


100 

25 

4 

200 


10. Kaposi's Tar Lotion : 








R. 01. rusci, 

Etheris sulphuris, 1 
Alcoholis, / 
Filter and add 

01. lavandulae, 




50 
aa 75 

2 


parts. 
u 

u 


Used in psoriasis. 








11. Kummerf eld' s Lotion : 








R. Spts campliorae, \ 
Spts. lavandulae, J 
Sulph praecip., 
Aq. cologniensis, 
Aq. destil., 




aa ^ ss ; 2 
gr. xv ; 1 

sj ; ^ 
iij; eo 




For cosmetique. 








12. Liquor Picis Alkalinus : 








R . Picis liquidae, 
Potass, causticae, 
Aquae, 




3 v ; 


25 
12 
100 


5 



535 



M. 



M. 



M. 



M. 



M. 



M. 



M. 

(Dissolve the potassa in the water and add slowly the tar in a mortar 
with friction ) 

In chronic eczema, or, diluted ten to twenty times, in acute eczema. 



536 



APPENDIX. 



13. Lotto Alba : 

Be . Potass, sulphurat., 
Zinci sulphat, 
Aquae rosse, 

In acne and rosacea. 



3J 



IV 



4 

128 



M. 



14. Lotio Ac. Boracis : 

R. Ac boracis, ^iv vel q s ; 16 

Etheris sulph. methyl , % v ; 160 

Spts. vini rect , ad 3 xx ; 640 M. 

In ringworm, after washing with hot water and soap and drying. 
Smith ) 



:a. 



15. Lotio Plumbi et Opii: 

Bt ■ Liq. plumbi subacetat dil., ) - . 



Tinct opii, 
Aquae, 

In acute inflammatory conditions. 

16. R. /3-naphthol, 

Spts sapo. viridis, 
Alcoholis, 
Bals. peruv., 
Sulph. loti, 

In sycosis. (Kaposi.) 

17. B-. Glycerole of starch, \ 

Oil of cade, J 

Green soap, 

Sig. In psoriasis. External use. 

18. Piffard's Substitute for Tar 

B Ac. salicyl , 
01. lavandulae, 
01 citronellae, 
01 pini sylvestris, ; 

01 ricini, ] 

In eczema capitis. 

19. Be . Sodii hypophosphitis, 

Glycerini, 
Aquae, 

For dermatitis venenata. (Morrow 



;j; 



32 



ad Oj; 500 



gr. xv ; 




1 


3 v J; 




25 


Sjss; 




50 


gtt XXX 


5 


2 


3 iJ ss ; 




10 


aa 


100 


parts 




5 


« 



gr. x-xxx 

3y ss ; 

fss; 
ij; 

3Jss; 






0.66-2 

10 

2 

64 

48 



32 

16 
256 



M. 



M. 



M. 



M. 



M. 





APPENDIX. 




20. 


Sulphur Lotion : 

R ■ Sulphuris loti, ] 
Alcohol., 










Etheris, }■ 


a a 


.^ij; 


8 




Glycerini, 










Potass, carb , J 










Aq. rosse, 




I^-iij; 


256 


Jsed 


in acne. 








21. 


Thymol Lotion : 










R. Thymol, 1 
Liq. potassa?, J 


a a 


3J; 


4 




Glycerini, 




.?ss; 


16 




Aq. sambuci, 




o Tii J ; 


256 



537 



M. 



For seborrhcea sicca capitis, 
the amount of thvmol. 



M. 

Also for pruritus cutanea-, with double 



22. Tinctura Saponis Viridis : 

R. Sapo. viridis, | 
Alcohol., J 

23. Tinct. Sapo?iis Co. of Hebra 

R. 01 cadini, 

Saponis viridis, 
Alcoholis, 
Filtra et adde 

Spts. lavandula?, 

Stimulant in chronic eczema. 

24. Vleminckx's Solution : 

R • Calcis viva?, 

Sulphur, sublimat 
Aq. destillat., 



a a 



E<jual parts 


sj; 


32 


3y; 


8 


3 iv ; 

fj; 
3*; 


16, 

32 
320 



M. 



M. 



M. 



Boil together with constant stirring until the mixture measures -is 
fluidounces, then filter. 

Useful in scabies, psoriasis, and acne. 



25. R . Zinci oxidi, 
Ac. carbol., 
Aqua? calcis, 
For dermatitis venenata. 



1. Bassorin Paste 

R . Basso rin, 
Dextrin, 

Glycerin, 
Water, 



IV 



3J; 

Oj; 



16 

4 
500 



ML 



i White.) 
c. Ointments. 



4S parts. 
25 " 
10 " 
ad 100 " 



M. 



23* 



538 



APPENDIX 



2. Bismuth Ointment: 

R . Bismuthi subnit., \ 
Kaolini, J 

Vaselini, 

For chloasma. (Unna. ) 



aa 3jss; 

gvj ad^jss; 30 



3. R . Ac. borici, 


gr. x ; 




Ac. salicylici, 


gr xv ; 


l 


Ungt. aquae rosfe, 


Ij; 


30 



For chromidrosis. (Van Harlingen.) 

4. Chrysarobln Ointment : 

R . Chrysarobin, gr. 1 ; 

Ac. salicylici, gr x ; 

Plasment vel \ ^ • . 

Adipis, J ^J > 

Used in psoriasis and ringworm. 







3 

30 



M. 



M. 



M. 



5. R. Chrysarobin, \ 
Ichthyol, j 


aa gr. lxxv ; 


5 


Ac. salicyl., 


gr xxx ; 


2 


Ungt. simpl , 


liij; 


100 



Used in leprosy. (Unna ) 

6. Diachylon Ointment (Hebra) : 

R . Olive oil, ^ xv ; 

Litharge, giij, gvj 

Boil together to a good consistence and add 



Oil of lavender, 

7. R. Hydrarg amnion., 
Bismuthi subnit , 
Ungt. aq. rosa?, 

Used in lentigo. (Hardaway.) 



8. R. Hydrarg. amnion., 

Hydrarg. chlor. mitis, 
Vaselini, 



3 J J ; 
3j; 



480 
120 



4 

30 



@j-ij ; 5-10 

^ij-iv; 10-20 
5 J ; 100 



M. 



M. 



M 



Used in seborrhea sicca capitis and pityriasis capitis. (Bronson ) 



9. R . Hydrarg. bichlor., gr. j-v ; 1-5 

Ac. carbol., gr. xx ; 20 

Ungt zinci oxid., ^j ; 500 

Used in lichen ruber. (Unna.) 



M. 



APPENDIX. 



539 



10. R . Ac. salicylici, gr. x ; 

Ungt hydrarg. ox. rub., 3 j ; 
Ungt. aquse rosse, 3 yj ; 

For blepharitis. (Webster ) 

11. R. Hydrarg. protiodid , 

Hydrarg. amnion., 
Ungt. simplicis, ^j 

Used in acne. (Duhring.) 



66 



4' 
24 



gr v-xv; 0.33-1 
gr x-xxx ; 0.66-21 



12. R. Hydrarg. sulph. rubri, gr. xv 



Sulph. sublimat 
Adipis, 
01. bergamot, 
Used in sycosis. (Behrend." 



ad 



q. s. 



13. R. Ungt. diachyli (Hebra), \ .- 
Ungt. zinci oxidi, J 

Ungt. hydrarg. ammon., 
Bismuth, subnitrat., 



z J ss ; 



32 



1 
24 

75| 



50 

10 
5 



M. 



M. 



M. 



M. 



aa 



In sycosis. (Robinson ) 

14. Lassa?''s Paste : 

R . Zinci oxidi, 
Amyli, _ 
Vaselini, 

As a protective application and as excipient for other drugs. 

15. Naphthol Ointment : 






32 



M. 



R. /3-napthol, 

Cretan preparat., 
Sapo. viridis, 
Adipis, 

Used in scabies. (Kaposi.) 


3iij> Bij ; 15 

^rjss; 10 

,^jss; 50 

ad | iij ; 100 


16. Naphthol Ointment: 




R. /3-napthol, 

Sulph precip., 
Vaselini, Y 
Sapo. viridis, J 


10 parts. 
50 " 

aa 25 " 


Used in acne. (Lassar.) 




17. R . Ac. salicylici, 

Sulphur, precip., 

Lanolini, 

Vaselini, 


2^3 parts. 
10-15 " 
70 " 
18 " 



M. 



M. 



M. 



For chromophytosis. (Brocq/ 



540 



APPENDIX. 



18. R. Sulphur., 

Potass, carb , 
Adip. benzoat., 
01. chamomilis, 

Used in scabies. (Wilson.) 

19. Helmerich's Ointment : 

R. Sulphur., 
Potass, carb., 
Adipis, 

Used in scabies. 



3j; 

3ss; 



3 vii J 



20. Wilkinson's Ointment (Hebra) : 

I 



R . Sulphuris, \ 
lini, j 



01. cadini 
Sapo viridis, 
Adipis, 
Cretse preparat., 

Used in scabies. 



aa 



21. R. 01. fagi, \ 
Flor. sulph., J 
Pulv. cretfe alb., 
Adipis, \ 

Sapo. viridis, J 

In sycosis. (H. Hebra.) 



aa 



aa 



3ss; 



3v; 



22. R . 01. cadini, \ M . 

Zinci oxidi, / o J 

Ungt. aquae rosse, ^j ; 

In chronic eczema. 



23. R. Glycerini, 

Gum. tragacanth., 
Sulph. sublimat , 
Potass, carbonat, 
01. lavandulse, 
01. menth. pip , 
01. caryophylli, 
01. cinnamomi, 

Used in scabies. (Bourguignon ) 

24. R . Zinc oxide, ) 

Zinc carbonate, / 
Rose ointment, 

In sycosis after shaving. (T. Fox.) 



aa 
ad 



a a 



3.1 



32 

8 
160 

2 



30 
15 

120 



20 

80 
10 



10 

5 

20 



2-4 
30 



200 parts. 

5 " 

100 " 

35 " 

1.5 " 



4 
32 



M. 



M. 



M. 



M. 



M. 



M. 



M. 



APPENDIX. 



541 



d. Miscellaneous 
1 



Anti-pruritic Powder , 

R . Camphori, 
Zinci oxidi, 
Amyli, 



Corn Remedy : 

R . Ac. salicylici, 

Ext. cannabis indicae, 
Alcoholis, 
JEtheris, 
Collodion flex., 



3ss; 


3 


3y; 


15 


3iv; 


30 



M. 



(Bulkley.; 



gr. xv ; 
gr. viij ; 

m>i; 

Vf[lxxv 



Apply with brush three times a day for one week, 
pick out corn. (Vigier. ) 



66 

M. 

Soak feet and 



3. Epilating Stick : 

R. Cerae flavae, ^iij ; 

Laccae in tabulis, 3 iv ; 

Picis burgundicae % x ; 

Gummidamar., ^j ss 5 



12 
16 
40 

48 



M. 



Make in stick one-half to one inch in diameter and two inches long. 
(Bulkley) 



4. Glycerin Jelly 



R . Gelatini, gr. xxv ; 
Glycerini, gr. ccxxv ; 
Aqua?, 3 iv ; 


1 
15 
16 


Glycerole of Subacetate of Lead: 




R . Plumbi acetat., gr. cxx ; 
Plumbi oxidi, gr. lxxxiv ; 
Glycerini, 3J ; 


8 
6 
32 



66 



M. 



M. 

Digest the lead in the glycerin heated to 300° F. in an oil bath for 
half an hour, constantly stirring. Filter in a chamber heated to 300° F. 

Dilute from three to seven times with water and glycerin, and use as 
astringent and sedative in chronic eczema (Squire ) 



INDEX 



4 BSCESS, 53 

A Absces tuberiforinis. 54 
Acantholysis, 54 
Acanthosis, 54 
Acid, oleic, 46 

oxynaphthoie. 4 V 
Acne, 54 

adenoid, 315 

albida, 319 

artificialis, 67 

atrophica, 68 

cachecticorum. r > v 

cornea, 68, 394 

cornee, 394 

erythematosa, 402 

fluente, 68, 428 

frontalis, 68 

hypertrophica, 69 

indurata. 56 

keloid. 69, 148 

ir.entagra, 69, 437 

miliare scrofuleuse. 68 

miliaris, 69 

necrotica, 68 

pilaris, 68 

rodens. 68, 69 

rosacea, 402 

rosee, 402 

scrofulosoriun, 69 

sebacea, 42S 
cornea, 394 

sebacee, 42 S 
cornee, 27"> 

-irnplex. 55 

sycosis, 437 

syphilitica, 69 

tuberculoide, 69 

varioliformis, 68, 321 

vulgaris, 55 



Achorion Schoenleinii, 22^ 

Achroma, 290 

Acrochordon, 69 

Acrodynia. 70 

Addison's keloid, 70 

Adenoma, 70 

Adenotrichie, 437 

Agnine, 46 

Ainhum, 70 

Albinism, 71 

Aleppo boil, bontou. or evil, 71 

AJoidite progressive. 71. 420 

Algor progressivus, 71 

Alopecia, 71 

adnata, 71 

areata, 79 

circumscripta. 79 

follicularis, 7 

furfuracea. 76 

pityrodes, 76 

prematura idiopathica, 
symptomatica, 75 

senilis. 72 

syphilitica, 7 v 
Alopecie innominee. S 
Alphos, 381 
Anaesthesia, 85 
Anatomical tubercle, 503 
Angioma, So, 331 

cavernosum, 382 

pigmentosum et atrophicum. 
88 
Angio-keratoma. 
Angioses, 86 
Anhidrosis, SQ 
Anonychia. 87 
Anthrarobin. 46 
Anthrax, 102, 399 
Area celsi, 79 



544 



INDEX. 



Area occidentalis diffluens, 79 
Argyria, 87 
Aristol, 46 

Arrectores pilorum, 34 
Arthritidepseudo-exanthematique, 

87 
Arzneiexantheme, 96 
Asteatosis, 87 
Atheroma, 87 
Atrophia pilorum propria, 92 

unguium, 96 
Atrophoderma, 87 

albidum, 90 

idiopathica diffusa, 90 

pigmentosum, 89 

senilis, 90 

striatum et maculatum, 91 
Aussatz, 284 
Autographism, 96 

t)AD disorder, 447 
) Baker's itch, 96, 180 
Baldness, 71 
Barbadoes leg, 96, 189 
Barber's itch, 96, 437, 492. 
Bartfinne, 96, 437 

parasitische, 492 
Bartflechte, 96, 437 
Bassorin, 46 
Birth-mark, 332 
Biskra bouton or beule, 96 
Blackheads, 117 
Blasenausschlag, 96, 352 
Blutfleckenkrankheit, 96, 394 
Blutgeschwur, 96 
Blutschwar, 96 
Blutschweiss, 96 
Boil, 96, 237 
Bouton, 97 

Bouton d' Amboine, 97 
Brandrose, 97 
Brandschwar, 102 
Bricklayer's itch, 97, 180 
Bromidrosis, 97 
Bucnemia tropica, 98, 189 
Bulla, the, 38 

nACOTKOPHIA folliculorum, 
\j 278, 394 

Calculi, cutaneous, 98, 320 



Callositas, 98 

Callus, 98 

Calotte, the, 229 

Calvezza, 71 

Calvities, 71 

Cancer en cuirasse, 106 

tubereux, 272 
Cancroide, 99, 195 
Canities, 100 
Caraate, 362 
Carbuncle, 102 
Carcinoma, 105 

lenticulare, 106 

melanodes, 106 

tuberosum, 10(5 
Chair du poule, 107, 1 22 
Chalastodermia, 149 
Chaleur du foie, 107 
Chancre, 107, 448 
Chap, 107 
Charbon, 107, 399 
Cheiro-pompholvx, 107, 370 
Chelis or cheloide, 107, 272 
Chicken-pox, 515 
Chignon fungus, 487 
Chilblain, 107, 126 
Chloasma, 107, 111 
Chorioblastosis, 110 
Chorionitis, 110, 421 
Chromidrosis, 110 
Chromophytosis, 111 
Cicatrix, the, 40 
Cingulum, 115 
Claret stain, 332 
Classification, 49 
Clastothrix, 93, 115 
Clavus, 115 
Cnidosis, 116, 509 
Collodion, 45 

Colloid degeneration of the skin, 
116 

milium, 116 
Comedo, 117 
Condyloma, 121 
Congelatio, 121, 126 
Connective tissue, subcutaneous, 28 
Corium, 28 
Corn, 115 
Cornu cutaneum, 121 

humanum, 121 
Couperose, 402 






INDEX. 



545 



Grasses parasitaires, 111, 122 

Creolin, 47 

Crusta lactea, 122, 174 

Crust, the, 39 

Cute, 362 

Cutis anserina, 122 

pendula, 149 

tensa chronica, 122, 421 

unctuosa, 122, 428 
Cyanopathie cutanee, 110 
Cyanosis, 122 
Cyst, sebaceous, 427 
Cysticercus cellulosa? cutis, 122 
Cysto-adenoma, 122 



DACTYLITIS, 473 
Dandruff, 123 
Dartre pustuleuse mentagre, 437 

rongeante, 309 

vive, 153 
Dartrous diathesis, 123 
Dasyma, 254 

Decrepitude infantile, 123 
Defluvium capillorum, 79 
Defcedatio unguium, 123 
Delhi boil, 123 
Demodex folliculorum, 118 
Dermalgia, 123 
Dermatalgia, 123 
Dermatitis, 124 

ambustionis, 124 

calorica, 124 

congelationis, 126 

contusiforme, 217 

epidemica, 131 

exfoliativa, 134 

neonatorum, 136 

fungoid, 327 

gangrenosa, 136 
infantum, 138 

glandularis erythematosa, 303 

herpetiformis, 139 

malignant papillary, 339 

medicamentosa, 144 

papillaris capillitii, 148 

papillomatosa capillitii, 148 

traumatica, 127 

venenata, 127 
Dermatol, 47 
Dermatolysis, 149 



Derm ato mycosis favosa, 223 

Dermatomykosis tonsurans, 490 

Dermato-sclerosis, 421 

Dermatosis Kaposi, 88 

Diabetide, 150 

Diagnosis, 34 

Distichiasis, 151 

Don'ts, 49 

Dracontiasis, 243 

Durillon, 98 

Dysidrosis, 151, 370 



ECDERMOPTOSIS, 321 
Ecthyma, 151 

infantile gangreneux, 138 
terebrant de l'enfance, 138 
Eczema, 153 

ani, 172 

aurium, 173 

barbae, 174 

capitis, 174 

crurum, 176 

exfoliativum, 132 

foliaceum, 132 

genitalium, 177 

hypertrophicum, 327 

infantile, 184 

intertrigo, 178 

labiorum, 178 

mammarum, 178 

mammellarum, 178 

manuum, 180 

marginatum, 187, 488 

narium, 181 

palpebrarum, 181 

pedum, 182 

seborrhoicum, 187 

tuberosum, 327 

unguium, 182 

universal, 183 
Elephantiasis, 190 

Graecorum, 283 
Emphysema, 194 
Endurcissement athrepsique, 420 

du tissu cellulaire, 194, 420 
Engelures, 194 
Ephelides, 281 
Ephidrosis, 251 

cruenta, 19, 243 

tincta, 110 



546 



INDEX. 



Epidermis, 25 
Epidermolysis, 194 
Epithelialkrebs, 195 
Epitheliom kystique benin, 195 
Epithelioma, 195 

contagiosum, 201, 321 
Epitheliomatose eczematoide de la 
mamelle, 339 

pigment aire, 88 
Equinia, 201 
Erbgrind, 202, 223 
Erysipelas, 202 
Erysipeloid, 206 
Erythanthema, 207 
Erythema, 207 

exudativum, 213 

fugax, 210 

gangrenosum, 220 

hypersemicum, 207 

intertrigo, 208 

iris, 216 . 

lseve, 210 

mamelonne, 220 

multiforme, 214 

neonatorum, 211 

nodosum, 217 

paratrimma, 210 

pernio, 208 

roseola, 210 

scarlatiniforme, 212 

simplex, 208 

urticans, 210 
Erytheme centrifuge, 303 

papuleux desquamatif, 363 
Erythrasma, 220 
Erythrodermies exfoliantes, 132 
Erythromelalgia, 222 
Esthiomene, 222, 309 
Europhene, 47 
Exanthemata, 222 
Excoriation, the, 40 



i;AECY, 201, 223 

l 1 Favus, 223 

Feuergiirtel, 232, 523 

Feuermal, 232, 331 

Fibroma, 232 

fungoides, 234, 327 
lipomatoses, 234, 51 9 
molluscum, 232 



Fibromyoma, 234, 329 

Figwart, 234 

Fikosis, 437 

Filaria sanguinis hominis, 192, 234 

medinensis, 234, 243 
Finnen, 54, 234 

Fischschuppenausschlag, 234, 261 
Fish-skin disease, 235, 261 
Fissure, the, 40 

Flachenkatarrh der haut, 153, 235 
Flachenkrebs, 235 
Fleckenmal, 235, 330 
Flechte, fressende, 309 

kleien, 111 

nassende, 153 
Fleshworms, 117 
Fluxus sebaceus, 235, 428 
Folliculitis barbre, 235, 437 

decalvans, 235 

pilorum, 437 

rubra, 236 
Fragilitas crinium, 92 
Framboesia, 148, 236, 522 
Freckles, 236, 281 
Frieselausschlag, 236, 318 
Fuchsine, 47 

Fungous foot of India, 236 
Furunculus, 237 

orientalis, 242 
Furunculi atonici, 151 



GALE, 411 
Gallacetophenone, 47 
Gangrene, symmetrical, 137, 242 
Gangrenes multiples cachectiques, 

138 
Gansehaut, 122, 242 
Gefassmaler, 242, 331 
Gelatin preparations, 46 
Geromorphisme cutane, 242 
Gesichts' atrophie, 91, 242 
Glanders, 201, 242 
Glanzhaut, 91, 242 
Glossy skin, 91, 242 
Gneis, 242, 428 

Gommes scrofuleuses, 242, 426 
Goose-flesh, 122 
Granuloma fungoides, 243, 327 
Grayness, 100 
Greisenhaftigheit der kinder, 243 



INDEX 



547 



Grocer's itch, 180, 243 
Grubs, 117 
Grutum, 319 

Guinea-worm disease, 243 
Gumma, 243, 463 
Gune, 243 

Gurtelkrankheit, 243, 523 
Gutta rosacea seu rosea, 402 



HAARMENSCHEN, 243, 254 
Hsematidrosis, 243 
Hsemorrhcea petechialis, 244, 394 
Hair, anatomy of, 30 

ringed, 101 

superfluous, 254 
Hand and foot disease, 358 
Harlequin foetus, 263 
Hautfmne, 244 
Hautgries, 244 
Hauthorn, 121, 244 
Hautkrebs, 244 
Hautsclerem, 421 
Heat eruption, 153 
Hemorrhagic cutanee, 244 
Herpes circine parasitaire, 490 

circinatus, 249, 488, 490 
bullosus, 249 

cretace, 249 

esthiomenos, 309 

facialis, 244 

gestationis, 249 

imbrique, 249 

iris, 249 

parasitaires, 249 

phlyctsenoides, 249 

progenitalis, 247 

pustulosus mentagra, 437 

squamosus, 490 

tonsurans, 249, 490 
barbae, 492 
maculosus, 363 

tonsurante, 490 

zoster, 249, 523 
Herpetide, 249 

exfoliatives, 132 

maligne exfoliative, 249 
Hide-bound disease, 421 
Hirsuties, 254 
Hives, 509 
Homines pilosi, 250, 254 



Homines sylvestris, 250, 254 
Horn, cutaneous, 121 
Hiihnerauge, 115, 250 
Hutchinson's teeth, 472 
Hyalom der haut, 116 
Hydradenomes eruptifs, 250 
Hydroa, 250 

bulleux, 250 
Hydro-adenitis, 250 
Hydroxylamine, 47 
Hygroma cysticum colli congeni- 

tum, 250 
Hyperesthesia, 250 
Hyperidrosis, symptoms, 251 
Hyperkeratosis follicularis, 278 
Hypertrichosis, 254 
Hypohidrosis, 261 
Hystricismus, 261 



1 CHTH YOL, 48 . 

1 Ichthyosis, 261 

Ichthyosis follicularis, 275, 278, 394 

palmaris et plantaris, 99 

sebacea cornea, 394, 428 
Idrosis, 251 
Ignis sacer, 265, 523 
Impetigo contagiosa, 266 

granulata, 271 

herpetiformis, 271 

parasitica, 266 

simplex, 266 
Induratio telese cellulosse, 419 
Inflammatory fungoid neoplasm, 

272 
Initial lesion of syphilis, 448 
Intertrigo, 208, 272 
Ionthus, 54 
Itch, 411 



J 



UCKBLATTERN, 372 



KAHLHEIT, 71, 272 
Kelis, 272 
Keloid, 273 

of Addison, 325 
of Alibert, 275 
Keratodermie symetrique des ex- 
tremites, 99 



548 



INDEX. 



Keratoma follicularis, 263 

palmare et plantare, 98 
Keratosis circumscripta, 275 

diffusa, 263, 278 

follicularis, 276 

pigmentosa, 278 

pilaris, 278 

senilis, 279 
Kerion, 279 
Knollenkrebs, 272, 281 
Kohlenbeule, 281 
Koltun, 369 
Kopskurv, 281 
Kratze, 411 
Kraurosis vulvae, 281 
Kreisfleckige Kahlheit, 80 
Kupferfinne, 281, 402 
Kupferrose, 281, 402 
Kupfriges gesicht, 281, 402 



T ANOLIN, 46 
\j Lausesucht, 281 
Leichdorn, 115, 361 
Leiomyoma cutis, 281 
Lentigo, 281 

maligna, 88 
Leontiasis, 283, 284 
Lepothrix, 283, 487 
Lepra, 284, 381 

alphos, 381 

arabum, 284 

vulgaire, 290 
Leprosy, 284 

Lombardian, 350 
Leucasmus, 290 
Leucoderma, 290 
Leucopathia, 290 

unguium, 293 
Leucoplakia, 293 
Leuksethiopes, 293 
Lichen circinatus, 294, 428, 430 

hypertrophicus, 300 

menti, 437 

obtusus, 300 

pilaris, 278 

planus, 298 

polymorphe chronique, 301 

ruber acuminatus, 295 
moniliformis, 300 

scrofulosorum, 302 



Lichen simplex, 155, 303 

spinulosum, 394 

syphiliticus, 303 

tropicus, 318 

urticatus, 303 

verrucosus, 300 
Lineae albicantes, 303 
Linsenmal, 330 
Liodermia essentialis cum melanosi, 

etc , 88 
Lipoma, 303 
Liquor guttae perchse, 45 
Liver spot, 107 
Lousiness, 344 
Lues, 303, 447 
Lupoid acne, 315 
Lupus erythematodes, 303 

erythematosus, 304 

exedens, 309 

exfoliativa, 309 

exulcerans, 309 

hypertrophicus, 310 

lymphaticus, 316 

miliaris, 315 

papillaire verruqueux, 503 

papillomatosus, 310 

sclereux, 309, 503 

sebaceus, 303, 309 

superficialis, 303, 309 

tuberculosus, 309 

verrucosus, 309, 310, 503 

vorax, 309 

vulgaris, 309 
Lustseuche, 447 
Lymphadenie cutanee, 327 
Lymphadenoma, 315 
Lymphangiectasis, 315 
Lymphangioma, 316 

tuberosum multiplex, 317 
Lymphodermia perniciosa, 317, 327 
Lymphorrhagia pachydermia, 316 
Lymphosarcoma, 317 



MACULE, the, 36 
Maculae caeruleae, 346 
et striae atrophica^, 317 
Madesis, 317 
Madura foot, 236 
Mai de los pintos, 362 
la rosa, 350 



INDEX, 



549 



Mai roxo, 350 

Maladie des vagabonds, 317 

Malum venereum, 447 

Mamillaris maligna, 339 

Masque, 107 

Mask, 107 

Measles, 324 

Meissner's corpuscles, 29 

Melanoderma, 317 

Melasma, 317 

Melanosarcoma, 318 

Melanosis lenticularis progressiva, 

88 
Melastearrhee, 110 
Melitagra, 318 
Mentagra, 318, 437 
Microsporon anomaeon, 364 

furfur, 113 
Miliaria, 318 
Miliary fever, 319 
Milium, 319 
Mitesser, 320 
Mole, pigmentary, 330 
Molluscum cholesterique, 321, 519 

contagiosum, 321 

epitheliale, 321 

fibrosum, 232 

pendulum, 232 

sebaceum. 321 

sessile, 321 

simplex, 232 

verrucosum, 321 
Monilethrix, 324 
Morbilli, 324 
Morbus elephas, 189, 324 

gallicus, 447 

hispanicus, 417 

indicus, 447 

italicus, 447 

maculosus Werlhoffii, 396 

neapolitanus, 447 

pediculare, 344 
Morphoea, 325 
Morpion, 327 
Morvan's disease, 327 
Moth patch, 107 
Mother's mark, 330 
Mucous patch, 455 
Myasis externa dermatosa, 327 
Mycetoma, 236, 327 
Mycosis frambcesiodes, 148 



Mycosis, fungoides, 327 

microsporina, 111, 329 
Myoma, 329 
Myxcedema, 329 



V .EVUS araneus, 335, 486 
l\ flammeus, 332 

lipomatodes, 330 

pigmentosus, 330 

pilosus, 330 

sanguineous, 331 

simplex, 333 

spilus, 330 

tuberosus, 332 

vascularis, 332 

venous, 332 

verrucosus, 330 
Narbengeschwulst, 335 
Kails, anatomy of, 32 
Narben keloid, 335 
Neoplasm, inflammatory fungoid, 

327 
Nerven neevus, 335 
Nesselausschlag, 335, 509 
Nesselsuch, 509 
Nettle rash, 335, 509 
Neuralgia of the skin, 123 
Neuroma cutis, 335 
Nodules, ephemeral cutaneous, 335 

subcutaneous rheumatismal, 
335 
Nodosites non-erythemateuses des 

arthritiques, 335 
Noli me tangere, 309 
Nodulus laqueatus, 336 



fPDEMA cutis, 336 

VJ_j (Edema neonatorum, 336 

Oil de Perdrix, 337 

Oleum chcenoceti, 46 

physeteris, 46 
Oligamie, 337 
Oligosteatoses, 337 
Oligotrichia, 337 
Onychatrophia, 337 
Onychauxis, 337 
Onychia, 338 
Onychogryphosis, 337 
Onychomycosis, 339 



550 



INDEX. 



Ophiasis, 80 
Osmidrosis, 97 



PACHYDERMATOCELE, 149, 
339 
Pachydermia, 339 
Pacinian corpuscles, 30 
Paget' s disease of the nipple, 339 
Panaritium, 342 
Panne hepatique, 107 
Panniculus adiposus, 28 
Panaris nerveux, 341 
Papillar beerschwamahnliche mul- 
tiple Geschwulste der Haul, 327 
Papilloma, 342 

neuropathic, 335 
Papule, the, 36 
Parangi, 522 
Parasitic diseases, 342 
Paronychia, 343 
Pastes, 45 

Patients, examination of, 44 
Paxton's disease, 344, 487 
Pedicularia, 344 
Pediculosis, 344 

capitis, 344 

pubis, 346 

vestimentorum, 345 
Pelade, 80 

Peliosis rheumatica, 397 
Pelioma typhosum, 350 
Pellagra, 350 
Pemfigo, 352 
Pemphigus, 352 

foliaceus, 354 

gangrsenosus, 138 

neonatorum, 354 

pruriginosus, 354 

vegetans, 354 

vulgaris, 352 
Perforating ulcer of foot, 358 
Periadenitis sudoripara, 359 
Perifolliculitis suppurees et con- 

glomerees en placards, 359 
Perionyxis, 360 
Perisarcoma, 400 
Perleche, 360 
Pernio, 126, 361 
Pfundnase, 361 
Phagmesis, 361 



Phlyzacia agria, 151 
Phthiriasis, 354, 341 
Phyto-alopecia, 80 
Pian, 522 

ruboide, 148 
Piebald-skin, 290 
Piedra, 361 
Pigmentmal, 330 
Pigmentgeschwulst, 362 
Pigmentkrebs, 362 

sarcoma, 362 
Pimple, 54, 362 
Pinta, 362 
Pityriasis. 428 

capitis, 363 

circine et margine, 363 

maculata et circinata, 363 

nigricans, 110 

parasitaire, 111 

pilaris, 278 

rosea, 363 

rubra, 132 

pilaris, 366 

versicolor, 111 
Plaques des Fumeurs, 369 
Plasment, 46 
Plica Polonica, 369 
Plique polonaise, 369 
Podelcoma, 369 
Poils accidentels, 254 
Poliothrix, 100 
Poliotes, 370 
Polyidrosis, 251 
Polypapilloma Tropicum, 370 
Polytrichia, 254 
Pompholyx, 352, 370 
Porcellanfriesel, 372, 509 
Porcupine disease, 372 
Porrigo, 223 

contagiosa, 266 

decalvans, 80 

favosa, 223, 372 

purpurans, 372, 490 

granule, 372 

lavalis, 223 

lupinosa, 223 
Porrigophyta scutulata, 223 
Portwine mark, 332 
Pox, 447 
Prairie itch, 372 
Prickly heat, 318, 372 



INDEX. 



551 



Pronunciation, scheme of, 53 

Prurigo, 373 

Pruritus, cutaneous, 372 

hienialis, 377, 380 
Pseudo exantheme erytheniato- 
desquamatif, 380 

erysipelas, 380 

leucaemia cutis, 380 
Psora, 381 
Psoriasis, 381 
Psorospermose folliculaire vege- 

tante, 275 
Psorospermosis follicularis cutis, 

275, 394 
Pterygium, 394 
Purpura, 394 
Pustula maligna, 399 
Pustule, the, 38 



Q 



CIXQUAUD'S disease, 235, 400 
Quirica, 362 



RADESYGE, 400 
Raymond's disease, 137 
Eed gum, 400 
Eesorcin, 48 
Eete Malpighii, 27 
Eheumatokelis, 400 
Ehinophyma, 400, 403 
Ehinoscleroma, 400 
Ehus poisoning, 402 
Eingkurv, 402, 490 
Eingworm, 402, 492 

honeycomb, 250 

of the body, 488 

of the scalp, 490 

Polish, 369 
Eisipola lombarda, 350 
Eitter's disease, 136, 402 
Eodent ulcer, 197, 402 
Eosacea, 403 
Eosee, 402, 408 
Eose rash, 408 
Eoseola, 210, 408 

syphilitica, 408 

pityriaca, 363 

squameuse, 408 
Eotheln, 408 
Eothlauf, 408 



Eubeola, 324 
Eupia, 408, 462 

escharotica, 138 



C ALOL, 48 

O Salt rheum, 153 

Sarcocele, Egyptian, 409 

Sarcoma, 409 

Sarcomatosis generalis, 327 

Satyriasis, 284, 411 

Salzfluss, 153 

Sauriasis, 261 

Sauroderma, 394 

Scabies, 411 

Scale, the, 39 

Scall or scald, 153 

Scalp, hygiene of, 74 

Scarlatina symptoms, 417 

Scheerende flechte, 419, 488, 490 

Schmeerfluss, 419 

Schuppenflechte, 381, 419 

Scissura pilorum, 92, 419 

Sclerem der neugeboren, 420 

Sclerema neonatorum, 421 

Scleriasis, 421 

Sclerodactylia 421, 423 

Scleroderma, 421 

circumscribed, 325 
Sclerostenosis, 424 
Scrofulide boutonneuse benigne, 
372, 424 

crustacee ulcereuse, 424 

erythemateuse, 303, 424 

tuberculeuse, 309, 424 
Scrofuloderma, 424 

ulceratiye, 327 

yerrucosum, 427, 503 
Scurvy, land, 396 
Sebaceous glands, anatomy of, 33 
Seborrhagia, 428 
Seborrhea, 428 

. congestiva, 303, 436 

nigricans, 110 
Seborrheal eczema, 436 
Shingles, 436, 523 
Sicosi parasitaria, 492 
Siderosis, 436 

Skin, anatomv and phvsiologv of, 
25 

lesions of, 34 



552 



INDEX. 



Smallpox, 515 
Soaps, medicated, 46 
Sommersprosse, 281, 436 
Spargosis, 437 
Spedalskhed, 284, 437 
Spaceloderma, 136, 436 
Spider cancer, 437, 486 
Spitze condylom, 437 
Spotted sickness, 362 
Stearrhoea, 428, 437 

nigricans, 110 
Steartorrhoea, 428, 437 
Steatoma, 437 
Stigmasie, 437 
Stigmata, 437 
Stinkschweiss, 437 
Stonepock, 54, 437 
Stratum corneum, 27 

mucosum, 27 
Striae et maculae atrophica?, 437 
Strophulus, 437 

albidus, 319, 437 

prurigneux, 372, 437 
Struma, 437 
Sndamina, 318, 437 
Sudatoria, 251, 437 
Sudor urinosus. 437 
Sueurs.coloraes, 437 
Sweat glands, anatomy of, 33 

blue, 110 

green, 111 

red, 111 

yellow, 110, 111 
Sweating, excessive, 437 
Sycosis, 437 

capillitii, 148 

contagiosa, 447 

franibcesia, 148 

non-parasitica, 336, 437, 447 

parasitaria, 447, 492 

parasitica, 343, 447, 492 
Syphilis, 447 

hereditary, 469 
Syringo cystadenoma, 484 

myelia, 484 



TACHE atrophique, 484 

1 bleue, 484 

cafe au lait, 484 
congenitale, 484 



Tache de feu, 332, 484 

hemorrhagique, 485 

hepatique, 107, 485 

ombrees, 485 

pigmentaire, 485 

yasculaire, 332, 485 

vineuse, 485 
Tactile corpuscles, 29 
Tan, 485 
Tanne, 117, 485 
Tattoo, 485 
Teigne du pauvre, 223 

faveuse, 223, 485 

granulee, 485 

imbriquee, 485 

pelade, 80, 485 

tondante, 485, 490 

tonsurante, 485, 490 
Telangiectasis, 485 
Tetter, 153, 486 
Therapeutical notes, 45 
Tniol, 48 
Thilanin, 48 
Tinea amiantacea, 428, 486 

asbestina, 428, 486 

barbae, 492 

circinata, 486, 488 

cruris, 486 

decalvans, 80, 486 

favosa, 223, 486 

hcosa, 223 

furfuracea, 486 

imbricata, 486 

kerion, 279, 487 

lupinosa, 223 

maligna, 223 

nodosa, 361, 487 

sycosis, 489, 492 

tondens, 489, 490 

tonsurans, 487, 490 

trichophytina, 487 

vera, 223 

versicolor, 111, 487 
Tinna, 362 
Trichauxis, 254, 487 
Trichiasis, 487 
Trichoclasia, 93 
Trichoma, 369 
Trichomycose noueuse, 487 
Trichomycosis nodosa, 361, 487 
Trichomykosis capillitii, 279 



INDEX. 



553 



Trichomykosis favosa, 223 
Trichonosis cana, 100, 487 

discolor, 100, 487 

furfur acea, 487 

poliosis, 100 
Trichophytosis, 487 

barbae, 492 

capitis, 490 

corporis, 488 

unguium, 494 
Trichophytie sycosique, 492 
Trichophyton tonsurans, 495 
Trichoptylose, 93 
Trichoptilosis, 503 
Trichorrhexis nodosa, 93, 503 
Trichosis hirsuties, 254 

plica, 369 
Trichoxerosis, 503 
Tubercle, the, 37 
Tubercula miliaria, 503 

sebacea, 503 

anatoniique, 503 
Tuberculum sebaceum, 319 
Tuberculosis cutis, 503 

verrucosa cutis, 503 
Tumenol, 48 

Tumeurs folliculeuses, 506 
Tumor, the, 39 

multiple fungoid papilloma- 
tous, 327 
Tumores sebiparis, 506 
Tvloma, 98, 506 
Tylosis, 98, 506 
Tylosis linguae, 506 

1TLCER, 40, 506 
U grave, 236, 508 

perforating, of the foot, 35S 

rodens, 508 
Ulerythema, 303, 508 
Uridrosis, 509 
Urticaire, 509 
Urticaria, 509 

pigmentosa, 513 



V 



ACCLXAL eruptions, 514 
Varicella, 515 

gangrenosa, 138 



Variola, 515 
Varus, 54, 516 
Vegetation dermique, 516 
Venereal wart, 516 
Verbrennuug, 516 
Verole, 447 
Verruca, 516 

necrogenica, 503, 518 
Verrue, 516, 518 
Verrugas, endemic, 518, 522 
Vesicle, the, 37 
Vibices, 518 
Vitiligo, 290, 518 

capitis, 80, 518 
Vitiligo idea, 518, 519 



WART, 516, 518 
Warts, post-mortem, 372, 
503 
Warze, 516, 518 
Warzenkrebs, 518 
Warzenmal, 518 
Washleather skin, 518 
Weichselzopf, 369, 518 
Wen, 518 
Wheal, the, 39 
Whelk, 54, 518 
Whitlow, melanotic, 409 



XANTHELASMA, 518, 519 
Xanthelasmoidea, 513 
Xanthoma, 519 

diabeticorum, 522 
Xeroderma, 261, 522 

pigmentosum, 88, 512 
Xerodermic pilaire, 278 



VAWS, 522 



yARAATH, 523 
Li Zona, 523 
Zoster, 523 



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VAUiiHAN (VICTOR C), and NOVY (FRED'K G.) PTOMAINES 
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16 LEA BROTHERS & CO.'S PUBLICATIONS. 

VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1893. 
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WALSHE (W. H.) PRACTICAL TREATISE ON THE DISEASES 
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WELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF 
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WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
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ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

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